Provider Demographics
NPI:1063638831
Name:NORTHLAKE PRIMARY CARE
Entity Type:Organization
Organization Name:NORTHLAKE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:LEFRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-641-6454
Mailing Address - Street 1:951 GAUSE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2937
Mailing Address - Country:US
Mailing Address - Phone:985-641-6454
Mailing Address - Fax:985-641-6458
Practice Address - Street 1:951 GAUSE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2937
Practice Address - Country:US
Practice Address - Phone:985-641-6454
Practice Address - Fax:985-641-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD11789R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA14557Medicaid
LAF92125Medicare UPIN
LA5CF79Medicare ID - Type Unspecified