Provider Demographics
NPI:1487643094
Name:LADERER, ROBERT CRAIG (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CRAIG
Last Name:LADERER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 GAUSE BLVD W STE 133
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-4127
Mailing Address - Country:US
Mailing Address - Phone:985-639-6010
Mailing Address - Fax:985-641-4131
Practice Address - Street 1:2170 GAUSE BLVD W STE 133
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-4127
Practice Address - Country:US
Practice Address - Phone:985-639-6010
Practice Address - Fax:985-641-4131
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B89813Medicare UPIN