Provider Demographics
NPI:1144211632
Name:BRONAUGH, HEATHER RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:RAE
Last Name:BRONAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 GAUSE BLVD STE 410
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2995
Mailing Address - Country:US
Mailing Address - Phone:985-280-9002
Mailing Address - Fax:985-781-0200
Practice Address - Street 1:1051 GAUSE BLVD STE 410
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2995
Practice Address - Country:US
Practice Address - Phone:985-280-9002
Practice Address - Fax:985-781-0200
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025950208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00336861OtherRAILROAD MEDICARE
LA1801020433OtherNPI SMH PHYSICIAN NETWORK
LA1420271Medicaid
LA5CR31OtherMEDICARE GROUP NUMBER
LAP00336861OtherRAILROAD MEDICARE
LA5CR31OtherMEDICARE GROUP NUMBER