=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063457554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY JUDE PALAZZO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 12/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 AVENUE F
-----------------------------------------------------
City | BOGALUSA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70427-3633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-732-1568
-----------------------------------------------------
Fax | 985-732-4458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 370
-----------------------------------------------------
City | BOGALUSA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70429-0370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-732-1568
-----------------------------------------------------
Fax | 985-732-4458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | MD.07154R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number | MD.07154R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------