=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053352328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTTI G MARAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 01/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 CALYPSO STREET; SUITE 210
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-966-6500
-----------------------------------------------------
Fax | 318-966-6501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 CALYPSO STREET; SUITE 210
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-966-6500
-----------------------------------------------------
Fax | 318-966-6501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 04712R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------