Provider Demographics
NPI:1083874929
Name:THURSTON, CARLA TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:TAYLOR
Last Name:THURSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CARLA
Other - Middle Name:MARIA
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1990 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-7055
Mailing Address - Country:US
Mailing Address - Phone:985-868-9300
Mailing Address - Fax:985-851-0053
Practice Address - Street 1:1302 LAKEWOOD DR STE 202
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1883
Practice Address - Country:US
Practice Address - Phone:985-300-5438
Practice Address - Fax:985-380-1029
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA204579207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1112763Medicaid
4Q332CG71OtherMEDICARE PTAN
LA43441YH4EMedicare PIN