=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912190646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUISIANA DERMATOLOGY ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2007
-----------------------------------------------------
Last Update Date | 08/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1014 W. ST. CLARE BOULEVARD SUITE 1040
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-743-2090
-----------------------------------------------------
Fax | 225-743-2093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 W ST.CLARE BOULEVARD SUITE 1040
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-743-2090
-----------------------------------------------------
Fax | 225-743-2093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | GLENDA IMES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-927-5663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------