Provider Demographics
NPI:1043385693
Name:CONKLIN, SCOTT GERARD (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:GERARD
Last Name:CONKLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 ANGELA ST
Mailing Address - Street 2:
Mailing Address - City:ARABI
Mailing Address - State:LA
Mailing Address - Zip Code:70032-1003
Mailing Address - Country:US
Mailing Address - Phone:504-415-4959
Mailing Address - Fax:
Practice Address - Street 1:619 E JUDGE PEREZ DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-5260
Practice Address - Country:US
Practice Address - Phone:504-309-8837
Practice Address - Fax:504-309-8954
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022229208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5BC18OtherMEDICARE GROUP
LAGO7810Medicare UPIN
LA5BC18OtherMEDICARE GROUP