Provider Demographics
NPI:1376506816
Name:AGRAMA, MAHMOUD TAYSEER (MD)
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:TAYSEER
Last Name:AGRAMA
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:P.O. BOX 1403
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-6151
Mailing Address - Country:US
Mailing Address - Phone:337-577-6196
Mailing Address - Fax:
Practice Address - Street 1:200 CORPORATE BOULEVARD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:800-893-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15519R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1468673Medicaid
D92569Medicare UPIN