Provider Demographics
NPI:1144218868
Name:STELLY, DEIDRE L (MD)
Entity Type:Individual
Prefix:DR
First Name:DEIDRE
Middle Name:L
Last Name:STELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 84460
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-4460
Mailing Address - Country:US
Mailing Address - Phone:225-526-0018
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:548 LAKES BLVD
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3248
Practice Address - Country:US
Practice Address - Phone:337-332-0661
Practice Address - Fax:337-332-0651
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA022380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1677655Medicaid
LAG24415Medicare UPIN
LA1677655Medicaid
LAP00163412Medicare PIN