Provider Demographics
NPI:1275550071
Name:JOLLY, TARUN (MD)
Entity Type:Individual
Prefix:DR
First Name:TARUN
Middle Name:
Last Name:JOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4520 WICHERS DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3135
Mailing Address - Country:US
Mailing Address - Phone:504-754-2334
Mailing Address - Fax:504-324-2078
Practice Address - Street 1:231 W ESPLANADE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2459
Practice Address - Country:US
Practice Address - Phone:504-754-2334
Practice Address - Fax:504-324-2078
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAMD.025631207L00000X
LA025631208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04658549Medicaid
LA1047104Medicaid
LA1047104Medicaid