Provider Demographics
NPI:1235269135
Name:ANDRE RAOUL BEZOU, M.D.
Entity Type:Organization
Organization Name:ANDRE RAOUL BEZOU, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONELLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-887-5555
Mailing Address - Street 1:2727 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5629
Mailing Address - Country:US
Mailing Address - Phone:985-892-8088
Mailing Address - Fax:
Practice Address - Street 1:2727 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5629
Practice Address - Country:US
Practice Address - Phone:985-892-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013197261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1161179Medicaid
LA1161179Medicaid
LA50269Medicare ID - Type Unspecified