Provider Demographics
NPI:1316026743
Name:MOCKLIN, KEVIN E (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:E
Last Name:MOCKLIN
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 1:4000 LOCK LANE.
Mailing Address - Street 2:# 14
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605
Mailing Address - Country:US
Mailing Address - Phone:337-494-2445
Mailing Address - Fax:337-430-6979
Practice Address - Street 1:4000 LOCK LANE.
Practice Address - Street 2:# 14
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605
Practice Address - Country:US
Practice Address - Phone:337-494-2445
Practice Address - Fax:337-430-6979
Is Sole Proprietor?:No
Enumeration Date:2006-11-05
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL014771207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1320072Medicaid
LA1320072Medicaid
LA5L198Medicare ID - Type Unspecified