Healthcare Provider Details

I. General information

NPI: 1083614879
Provider Name (Legal Business Name): ILEANA J TANDRON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 GAUSE BLVD E
SLIDELL LA
70461-4231
US

IV. Provider business mailing address

2240 GAUSE BLVD E
SLIDELL LA
70461-4231
US

V. Phone/Fax

Practice location:
  • Phone: 985-643-9704
  • Fax: 985-643-9545
Mailing address:
  • Phone: 985-643-9704
  • Fax: 985-643-9545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number019093
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: