Healthcare Provider Details

I. General information

NPI: 1255503082
Provider Name (Legal Business Name): JULIO E. IGLESIAS,M.D. A PROFESSIONAL MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BOUNDARY AVE SUITE A
WINNFIELD LA
71483-3427
US

IV. Provider business mailing address

301 W BOUNDARY AVE SUITE A
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 Code261Q00000X
TaxonomyClinic/Center
License Number05638R
License Number StateLA

VIII. Authorized Official

Name: DR. JULIO E IGLESIAS
Title or Position: PRESIDENT/M.D.
Credential: M.D.
Phone: 318-628-2108