Organization
MATHERNE DERMATOLOGY, LLC
Active
Organization
MATHERNE DERMATOLOGY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHELE DECKER MATHERNE (MANAGER)
(504) 975-9577
Entity
Organization
Contact information
Practice address
2100 AUDUBON AVE, THIBODAUX, LA 70301-5014
(985) 446-5888
(985) 446-5880
Mailing address
2100 AUDUBON AVE, THIBODAUX, LA 70301
(985) 446-5888
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
MD202680
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1500615
—
LA
01
—
4Q145DX54
INDIVIDUAL MEDICARE PTAN
—
01
—
5DX54
MEDICARE GROUP PTAN
LA
Enumeration date
07/12/2013
Last updated
04/19/2018
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