Individual
LOI DAI VO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1017 W FERTITTA BLVD, LEESVILLE, LA 71446-4646
(337) 239-2606
(337) 238-5748
Mailing address
1017 W FERTITTA BLVD, LEESVILLE, LA 71446-4646
(337) 239-2606
(337) 238-5748
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
11402R
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1663328
—
LA
Enumeration date
12/05/2005
Last updated
07/08/2007
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