Provider Demographics
NPI:1326008038
Name:KORDISCH, STANLEY R (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:R
Last Name:KORDISCH
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 1:4150 NELSON RD
Mailing Address - Street 2:BLDG C-10
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4148
Mailing Address - Country:US
Mailing Address - Phone:337-474-0653
Mailing Address - Fax:337-474-0639
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:BLDG C-10
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-474-0653
Practice Address - Fax:337-474-0639
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013813207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1303160Medicaid
LA5A656Medicare PIN
LA1303160Medicaid