Healthcare Provider Details

I. General information

NPI: 1205018017
Provider Name (Legal Business Name): KENNETH P. MAUTERER MD A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 N PINE ROAD
OLLA LA
71465
US

IV. Provider business mailing address

PO BOX 668
OLLA LA
71465-0668
US

V. Phone/Fax

Practice location:
  • Phone: 318-495-3131
  • Fax: 318-495-3677
Mailing address:
  • Phone: 318-495-3131
  • Fax: 318-495-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number012667
License Number StateLA

VIII. Authorized Official

Name: DR. KENNETH P MAUTERER
Title or Position: PRESIDENT
Credential: MD
Phone: 318-495-3131