Healthcare Provider Details

I. General information

NPI: 1912960444
Provider Name (Legal Business Name): MATTHEW A. MCQUEEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 JEFFERSON HWY
NEW ORLEANS LA
70121-2426
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-842-4747
  • Fax: 504-842-1242
Mailing address:
  • Phone: 504-842-4747
  • Fax: 504-842-1242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number10635R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: