Provider Demographics
NPI:1255501052
Name:WEBER, MIA H (MD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:H
Last Name:WEBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2439 MANHATTAN BLVD STE 501A
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-5328
Mailing Address - Country:US
Mailing Address - Phone:504-569-5327
Mailing Address - Fax:504-323-3153
Practice Address - Street 1:2439 MANHATTAN BLVD STE 501A
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-5328
Practice Address - Country:US
Practice Address - Phone:504-569-5327
Practice Address - Fax:504-323-3153
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.202558208000000X, 208000000X
LAMD202558208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508403Medicaid
MS02105071Medicaid
LA1508403Medicaid