MEDICARE: BAYOU DERMATOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1699636571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYOU DERMATOLOGY LLC

Provider Business Mailing Address
First Line	:	911 TECH DR
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-0701
Country	:	US
Telephone Number	:	318-265-6376
Fax Number	:	318-265-6377

Provider Business Practice Location Address
First Line	:	911 TECH DR
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-0701
Country	:	US
Telephone Number	:	318-265-6376
Fax Number	:	318-265-6377

Authorized Official
Title or Position	:	OWNER/MD
Name	:	JOSHUA MANDRELL
Credential	:	MD
Telephone Number	:	318-265-6376

Provider Enumeration Date	:	11/20/2025
Last Update Date	:	11/20/2025

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Directions to “BAYOU DERMATOLOGY LLC ” Practice Location

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