Provider Demographics
NPI:1518094010
Name:IBERIA DERMATOLOGY
Entity Type:Organization
Organization Name:IBERIA DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VENETIA
Authorized Official - Middle Name:MARIE NICOLE
Authorized Official - Last Name:PATOUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-560-1200
Mailing Address - Street 1:PO BOX 10938
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70562-0938
Mailing Address - Country:US
Mailing Address - Phone:337-560-1200
Mailing Address - Fax:337-560-5554
Practice Address - Street 1:602 N LEWIS ST
Practice Address - Street 2:SUITE 600
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2093
Practice Address - Country:US
Practice Address - Phone:337-560-1200
Practice Address - Fax:337-560-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023184207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1492485Medicaid
LAH25250Medicare UPIN
LA1492485Medicaid