Healthcare Provider Details

I. General information

NPI: 1063411361
Provider Name (Legal Business Name): MAHMOUD DAFTARY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 GAUSE BLVD. EAST
SLIDELL LA
70461
US

IV. Provider business mailing address

1514 JEFFERSON HIGHWAY
NEW ORLEANS LA
70121
US

V. Phone/Fax

Practice location:
  • Phone: 985-639-3777
  • Fax:
Mailing address:
  • Phone: 504-842-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number04535R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD.04535R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: