Healthcare Provider Details

I. General information

NPI: 1750382784
Provider Name (Legal Business Name): MICHAEL JUDE TARANTINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 ARBOR LN
NEW IBERIA LA
70563-2822
US

IV. Provider business mailing address

108 ARBOR LN
NEW IBERIA LA
70563-2822
US

V. Phone/Fax

Practice location:
  • Phone: 337-365-5881
  • Fax:
Mailing address:
  • Phone: 337-365-5881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number010736
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: