Provider Demographics
NPI:1265446389
Name:ARDOIN, BRENT C (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:C
Last Name:ARDOIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 POINCIANA AVE
Mailing Address - Street 2:
Mailing Address - City:MAMOU
Mailing Address - State:LA
Mailing Address - Zip Code:70554-2208
Mailing Address - Country:US
Mailing Address - Phone:337-468-0267
Mailing Address - Fax:337-468-2438
Practice Address - Street 1:728 POINCIANA AVE
Practice Address - Street 2:
Practice Address - City:MAMOU
Practice Address - State:LA
Practice Address - Zip Code:70554-2208
Practice Address - Country:US
Practice Address - Phone:337-468-0267
Practice Address - Fax:337-468-2438
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1347698Medicaid
LAB64078Medicare UPIN
LA1347698Medicaid