Healthcare Provider Details

I. General information

NPI: 1669878054
Provider Name (Legal Business Name): DENISE GOODFELLOW KERUT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 JEFFERSON HIGHWAY
RIVER RIDGE LA
70123
US

IV. Provider business mailing address

9605 JEFFERSON HIGHWAY
RIVER RIDGE LA
70123
US

V. Phone/Fax

Practice location:
  • Phone: 504-738-1604
  • Fax: 504-738-7860
Mailing address:
  • Phone: 504-738-1604
  • Fax: 504-738-7860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number09413R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: