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General NPI Number Information
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NPI Number | 1205018017
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Entity Type | Organization
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Legal Business Name | KENNETH P. MAUTERER MD A MEDICAL CORP
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 12/04/2007
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Provider Practice Location Address
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Address Line | 1148 N PINE ROAD
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City | OLLA
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State | LA
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Zip | 71465
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Country | US
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Telephone | 318-495-3131
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Fax | 318-495-3677
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Provider Business Mailing Address
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Address Line | PO BOX 668
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City | OLLA
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State | LA
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Zip | 71465-0668
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Country | US
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Telephone | 318-495-3131
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Fax | 318-495-3677
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH P MAUTERER
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Credential | MD
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Telephone | 318-495-3131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 012667
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License Number State | LA
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