Healthcare Provider Details

I. General information

NPI: 1699933077
Provider Name (Legal Business Name): MAYNARD E GARRETT MD APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 ROBERT BOULEVARD SUITE 104
SLIDELL LA
70458
US

IV. Provider business mailing address

985 ROBERT BOULEVARD SUITE 104
SLIDELL LA
70458
US

V. Phone/Fax

Practice location:
  • Phone: 985-847-1995
  • Fax: 985-847-1992
Mailing address:
  • Phone: 985-847-1995
  • Fax: 985-847-1992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberLA12053
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberLA12053
License Number StateLA

VIII. Authorized Official

Name: MR. MAYNARD E GARRETT JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 985-847-1995