Provider Demographics
NPI:1548601016
Name:MATHERNE DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:MATHERNE DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:DECKER
Authorized Official - Last Name:MATHERNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-975-9577
Mailing Address - Street 1:2100 AUDUBON AVE
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301
Mailing Address - Country:US
Mailing Address - Phone:985-446-5888
Mailing Address - Fax:
Practice Address - Street 1:2100 AUDUBON AVE
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5014
Practice Address - Country:US
Practice Address - Phone:985-446-5888
Practice Address - Fax:985-446-5880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-12
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD202680207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DX54OtherMEDICARE GROUP PTAN
LA1500615Medicaid
4Q145DX54OtherINDIVIDUAL MEDICARE PTAN