Provider Demographics
NPI:1235738634
Name:LOUISIANA RETINA A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LOUISIANA RETINA A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-523-7624
Mailing Address - Street 1:303 VETERANS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-4723
Mailing Address - Country:US
Mailing Address - Phone:225-242-9729
Mailing Address - Fax:
Practice Address - Street 1:303 VETERANS BLVD STE A
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-4723
Practice Address - Country:US
Practice Address - Phone:225-242-9729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty