Healthcare Provider Details

I. General information

NPI: 1437183670
Provider Name (Legal Business Name): PERIPHERAL VASCULAR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 ANDRE ST STE 101
NEW IBERIA LA
70563-2159
US

IV. Provider business mailing address

1100 ANDRE ST STE 101
NEW IBERIA LA
70563-2159
US

V. Phone/Fax

Practice location:
  • Phone: 337-369-9309
  • Fax: 337-365-8455
Mailing address:
  • Phone: 337-369-9309
  • Fax: 337-365-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD W DAUTERIVE JR.
Title or Position: DOCTOR
Credential: M.D.
Phone: 337-369-9309