Provider Demographics
NPI:1518965102
Name:MAYEUX, MARY ANGELA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANGELA
Last Name:MAYEUX
Suffix:
Gender:F
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:PO BOX 919229
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-9229
Mailing Address - Country:US
Mailing Address - Phone:337-289-8944
Mailing Address - Fax:337-571-0030
Practice Address - Street 1:4212 W CONGRESS ST STE 3100
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6771
Practice Address - Country:US
Practice Address - Phone:337-703-3201
Practice Address - Fax:337-703-3202
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2019-09-19
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
LA019577174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1379425Medicaid
LAD79809Medicare UPIN
LA1379425Medicaid