Provider Demographics
NPI:1255503082
Name:JULIO E. IGLESIAS,M.D. A PROFESSIONAL MEDICAL CORP
Entity Type:Organization
Organization Name:JULIO E. IGLESIAS,M.D. A PROFESSIONAL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:E
Authorized Official - Last Name:IGLESIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-628-2108
Mailing Address - Street 1:301 W BOUNDARY AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483-3427
Mailing Address - Country:US
Mailing Address - Phone:318-628-2108
Mailing Address - Fax:318-628-6211
Practice Address - Street 1:301 W BOUNDARY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3427
Practice Address - Country:US
Practice Address - Phone:318-628-2108
Practice Address - Fax:318-628-6211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05638R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1205213510OtherBLUE CROSS OF LOUISIANA
GA02000158OtherMC UNITED HEALTHCARE
LA1317519Medicaid
GA02000158OtherMC UNITED HEALTHCARE
LA52908Medicare PIN