Provider Demographics
NPI:1083617237
Name:M A CULASSO, LLC
Entity Type:Organization
Organization Name:M A CULASSO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CULASSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-646-0945
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70459-0729
Mailing Address - Country:US
Mailing Address - Phone:985-646-0945
Mailing Address - Fax:985-643-8510
Practice Address - Street 1:1520 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2208
Practice Address - Country:US
Practice Address - Phone:985-649-0945
Practice Address - Fax:985-643-8510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1444278Medicaid
LA5C856Medicare PIN