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General NPI Number Information
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NPI Number | 1760626170
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Entity Type | Organization
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Legal Business Name | MARK C MOUTON MD LLC
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Dates
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Enumeration Date | 04/29/2009
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Last Update Date | 07/01/2014
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Provider Practice Location Address
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Address Line | 12880 PLANK RD
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City | BAKER
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State | LA
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Zip | 70714-4909
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Country | US
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Telephone | 225-774-7111
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Fax | 225-774-7714
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Provider Business Mailing Address
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Address Line | 12880 PLANK RD
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City | BAKER
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State | LA
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Zip | 70714-4909
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Country | US
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Telephone | 225-774-7111
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Fax | 225-774-7714
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Authorized Official
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Title or Position | MEMBER
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Name | DR. MARK CHRISTIAN MOUTON
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Credential | MD
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Telephone | 504-621-3298
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MD.201233
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License Number State | LA
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