MEDICARE: DR. MIGNONNE C. MARY M.D.

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	207RB0002X	Obesity Medicine (Internal Medicine) Physician	024324	LA
2	207R00000X	Internal Medicine Physician	024324	LA

General Provider Information

NPI Number	:	1770611576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIGNONNE C. MARY M.D.

Provider Business Mailing Address
First Line	:	1224 SAINT CHARLES AVE
Second Line	:	SUITE 1-C
City	:	NEW ORLEANS
State	:	LA
Zip	:	70130-4334
Country	:	US
Telephone Number	:	504-301-1670
Fax Number	:	504-309-4413

Provider Business Practice Location Address
First Line	:	1224 SAINT CHARLES AVE
Second Line	:	SUITE 1-C
City	:	NEW ORLEANS
State	:	LA
Zip	:	70130-4334
Country	:	US
Telephone Number	:	504-301-1670
Fax Number	:	504-309-4413

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	08/03/2013

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