Provider Demographics
NPI:1366439549
Name:BREAST CENTER OF ACADIANA, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BREAST CENTER OF ACADIANA, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-504-5000
Mailing Address - Street 1:935 CAMELLIA BLVD.
Mailing Address - Street 2:STE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508
Mailing Address - Country:US
Mailing Address - Phone:337-456-7479
Mailing Address - Fax:337-504-5646
Practice Address - Street 1:935 CAMELLIA BLVD
Practice Address - Street 2:STE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6961
Practice Address - Country:US
Practice Address - Phone:337-504-5000
Practice Address - Fax:337-504-5646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1440744Medicaid
LA1440744Medicaid
LACH2062Medicare PIN