1942316450 NPI number — DR. BRYAN BERTUCCI M.D.

Table of content: DR. BRYAN BERTUCCI M.D. (NPI 1942316450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942316450 NPI number — DR. BRYAN BERTUCCI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERTUCCI
Provider First Name:
BRYAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942316450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7718 W JUDGE PEREZ DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARABI
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70032-1919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-271-8952
Provider Business Mailing Address Fax Number:
504-278-4692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
843 MILLING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LULING
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70070-4442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-785-5851
Provider Business Practice Location Address Fax Number:
504-278-4692
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  015628 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2137689 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 015628 . This is a "LA. LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1328031 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1444642 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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