Healthcare Provider Details

I. General information

NPI: 1235643891
Provider Name (Legal Business Name): ESTHETIC MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2017
Last Update Date: 11/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3769 PONTCHARTRAIN DR STE 3
SLIDELL LA
70458-4852
US

IV. Provider business mailing address

3769 PONTCHARTRAIN DR STE 3
SLIDELL LA
70458-4852
US

V. Phone/Fax

Practice location:
  • Phone: 985-641-5476
  • Fax:
Mailing address:
  • Phone: 985-641-5476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD016771
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number16771
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.206408
License Number StateLA

VIII. Authorized Official

Name: MRS. JENNIFER ROBIN BONNEY
Title or Position: MANAGER/ BILLING
Credential:
Phone: 228-254-0495