Provider Demographics
NPI:1235643891
Name:ESTHETIC MD
Entity Type:Organization
Organization Name:ESTHETIC MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/ BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:BONNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-254-0495
Mailing Address - Street 1:3769 PONTCHARTRAIN DR STE 3
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-4852
Mailing Address - Country:US
Mailing Address - Phone:985-641-5476
Mailing Address - Fax:
Practice Address - Street 1:3769 PONTCHARTRAIN DR STE 3
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-4852
Practice Address - Country:US
Practice Address - Phone:985-641-5476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-18
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD016771207N00000X
LA16771207ND0900X
LAMD.206408207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty