Provider Demographics
NPI:1205018017
Name:KENNETH P. MAUTERER MD A MEDICAL CORP
Entity Type:Organization
Organization Name:KENNETH P. MAUTERER MD A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:MAUTERER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-495-3131
Mailing Address - Street 1:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:OLLA
Mailing Address - State:LA
Mailing Address - Zip Code:71465-0668
Mailing Address - Country:US
Mailing Address - Phone:318-495-3131
Mailing Address - Fax:318-495-3677
Practice Address - Street 1:1148 N PINE ROAD
Practice Address - Street 2:
Practice Address - City:OLLA
Practice Address - State:LA
Practice Address - Zip Code:71465
Practice Address - Country:US
Practice Address - Phone:318-495-3131
Practice Address - Fax:318-495-3677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012667208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5F838Medicare PIN