Healthcare Provider Details

I. General information

NPI: 1720212392
Provider Name (Legal Business Name): HERBERT ICHINOSE, MD APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 ENGLEWOOD DR
SLIDELL LA
70458-3009
US

IV. Provider business mailing address

1361 ENGLEWOOD DR
SLIDELL LA
70458-3009
US

V. Phone/Fax

Practice location:
  • Phone: 985-781-9005
  • Fax: 985-781-9007
Mailing address:
  • Phone: 985-781-9005
  • Fax: 985-781-9007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Q00000X
TaxonomyPathology Specialist/Technologist
License NumberMD.008092
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code246QH0600X
TaxonomyHistology Specialist/Technologist
License NumberMD.008092
License Number StateLA

VIII. Authorized Official

Name: DR. HERBERT ICHINOSE
Title or Position: MEDICAL DIRECTOR, OWNER
Credential: MD
Phone: 985-781-9005