Provider Demographics
NPI:1053679530
Name:DAUTERIVE, MATTHEW EARLES
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:EARLES
Last Name:DAUTERIVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 HOSPITAL DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2852
Mailing Address - Country:US
Mailing Address - Phone:252-744-5258
Mailing Address - Fax:252-744-4887
Practice Address - Street 1:2309 E MAIN ST STE 500
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4046
Practice Address - Country:US
Practice Address - Phone:337-374-7315
Practice Address - Fax:337-374-7313
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA308116207RP1001X
NC2016-00561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease