Provider Demographics
NPI:1174659668
Name:LEBEAU, JAKE THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:THOMAS
Last Name:LEBEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 MICHAEL DEBAKEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8360
Mailing Address - Fax:337-312-6708
Practice Address - Street 1:501 MICHAEL DEBAKEY DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5724
Practice Address - Country:US
Practice Address - Phone:337-312-8246
Practice Address - Fax:337-497-1173
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.206026207RC0000X, 207RI0011X
MO2008026265208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2367102Medicaid
LA369167YH5NMedicare PIN
LA2367102Medicaid