Provider Demographics
NPI:1336129659
Name:COUSIN, ERIC EARL (SURFACE IDC)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:EARL
Last Name:COUSIN
Suffix:
Gender:M
Credentials:SURFACE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 INTREPID DR
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037-1358
Mailing Address - Country:US
Mailing Address - Phone:504-391-3643
Mailing Address - Fax:
Practice Address - Street 1:123 INTREPID DR
Practice Address - Street 2:
Practice Address - City:BELLE CHASSE
Practice Address - State:LA
Practice Address - Zip Code:70037-1358
Practice Address - Country:US
Practice Address - Phone:504-391-3643
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman