Provider Demographics
NPI:1164613758
Name:MOUTON, MARK CHRISTIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHRISTIAN
Last Name:MOUTON
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 1:12880 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-4909
Mailing Address - Country:US
Mailing Address - Phone:225-774-7111
Mailing Address - Fax:225-774-7714
Practice Address - Street 1:12880 PLANK RD
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-4909
Practice Address - Country:US
Practice Address - Phone:225-774-7111
Practice Address - Fax:225-774-7111
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201233207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1090484Medicaid
4N479DD21Medicare PIN