Provider Demographics
NPI:1063671956
Name:DEFATTA, MICHAEL BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BENJAMIN
Last Name:DEFATTA
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 1:1901 PERDIDO ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-1393
Mailing Address - Country:US
Mailing Address - Phone:504-568-6031
Mailing Address - Fax:
Practice Address - Street 1:1901 PERDIDO ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-1393
Practice Address - Country:US
Practice Address - Phone:504-568-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021226207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology