Provider Demographics
NPI:1053819706
Name:MOUTON, DAVID LEE (CNIM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:MOUTON
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-0187
Mailing Address - Country:US
Mailing Address - Phone:225-239-2301
Mailing Address - Fax:225-341-8526
Practice Address - Street 1:113 E SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-4008
Practice Address - Country:US
Practice Address - Phone:225-239-2301
Practice Address - Fax:225-341-8526
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3229246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic