Healthcare Provider Details

I. General information

NPI: 1902824063
Provider Name (Legal Business Name): LAURIANNE G WILD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 TULANE AVE SL57
NEW ORLEANS LA
70112-2632
US

IV. Provider business mailing address

1430 TULANE AVE SL57
NEW ORLEANS LA
70112-2632
US

V. Phone/Fax

Practice location:
  • Phone: 504-988-5584
  • Fax: 504-988-3686
Mailing address:
  • Phone: 504-988-5584
  • Fax: 504-988-3686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD.021069
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: