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General NPI Number Information
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NPI Number | 1821551573
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Entity Type | Organization
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Legal Business Name | MARA HASELTINE MD LLC
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Dates
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Enumeration Date | 04/10/2019
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Last Update Date | 04/10/2019
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Provider Practice Location Address
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Address Line | 3100 GALLERIA DR STE 203
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City | METAIRIE
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State | LA
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Zip | 70001-2196
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Country | US
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Telephone | 504-226-7873
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Fax | 504-704-1639
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Provider Business Mailing Address
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Address Line | 4921 BARONNE ST
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City | NEW ORLEANS
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State | LA
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Zip | 70115-4922
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Country | US
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Telephone | 504-226-7873
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARA HASELTINE
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Credential | MD
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Telephone | 504-226-7873
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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