Provider Demographics
NPI:1588600894
Name:ITELD, BRUCE J (MD,FACC,FCCP,FSCAI)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:J
Last Name:ITELD
Suffix:
Gender:M
Credentials:MD,FACC,FCCP,FSCAI
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 2209
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70459-2209
Mailing Address - Country:US
Mailing Address - Phone:985-649-2700
Mailing Address - Fax:985-649-2950
Practice Address - Street 1:1810 LINDBERG DR STE 2100
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-8064
Practice Address - Country:US
Practice Address - Phone:985-649-2700
Practice Address - Fax:985-649-2950
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012398207RC0000X, 207RI0011X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1136425Medicaid
LAB64006Medicare UPIN
LA52636Medicare ID - Type Unspecified