Provider Demographics
NPI:1568658086
Name:PROPHETE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PROPHETE MEDICAL CORPORATION
Other - Org Name:LIAUTAUD MORIN PROPHETE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LIAUTAUD
Authorized Official - Middle Name:MORIN
Authorized Official - Last Name:PROPHETE
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:209-826-4771
Mailing Address - Street 1:PO BOX 2236
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-2236
Mailing Address - Country:US
Mailing Address - Phone:209-826-4771
Mailing Address - Fax:209-826-8565
Practice Address - Street 1:502 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4649
Practice Address - Country:US
Practice Address - Phone:209-826-4771
Practice Address - Fax:209-826-8565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9842207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX98420Medicaid