Healthcare Provider Details

I. General information

NPI: 1346449949
Provider Name (Legal Business Name): MARY L. PUISSEGUR LUPO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 09/08/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 ROBERT E LEE BLVD SUITE 302
NEW ORLEANS LA
70124-2552
US

IV. Provider business mailing address

145 ROBERT E LEE BLVD SUITE 302
NEW ORLEANS LA
70124-2552
US

V. Phone/Fax

Practice location:
  • Phone: 504-777-3047
  • Fax: 504-288-1535
Mailing address:
  • Phone: 504-777-3047
  • Fax: 504-288-1535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY LUPO
Title or Position: OWNER
Credential: MD
Phone: 504-777-3047