Provider Demographics
NPI:1306027701
Name:ARDOIN, KIPP BURNETTE (MD)
Entity Type:Individual
Prefix:
First Name:KIPP
Middle Name:BURNETTE
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 1:2903 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8809
Mailing Address - Country:US
Mailing Address - Phone:337-478-6480
Mailing Address - Fax:
Practice Address - Street 1:2903 1ST AVE
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8809
Practice Address - Country:US
Practice Address - Phone:337-478-6480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAGETP.TUL.PED208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1002992Medicaid