Provider Demographics
NPI:1174508741
Name:KATTASH, MUDAR (MD)
Entity Type:Individual
Prefix:DR
First Name:MUDAR
Middle Name:
Last Name:KATTASH
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:PO BOX 7788
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605
Mailing Address - Country:US
Mailing Address - Phone:337-562-2293
Mailing Address - Fax:337-562-1469
Practice Address - Street 1:2005 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4139
Practice Address - Country:US
Practice Address - Phone:337-562-2293
Practice Address - Fax:337-562-1469
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12869R2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1544493Medicaid
LA1544493Medicaid
G85148Medicare UPIN