Healthcare Provider Details

I. General information

NPI: 1780663476
Provider Name (Legal Business Name): JULIO E IGLESIAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301A W BOUNDARY AVE
WINNFIELD LA
71483-3427
US

IV. Provider business mailing address

301A W BOUNDARY AVE
WINNFIELD LA
71483-3427
US

V. Phone/Fax

Practice location:
  • Phone: 318-628-2108
  • Fax: 318-628-6211
Mailing address:
  • Phone: 318-628-2108
  • Fax: 318-628-6211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number05638R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: