Provider Demographics
NPI:1609852474
Name:FOREMAN, MICHAEL DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DALE
Last Name:FOREMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:DALE
Other - Last Name:FOREMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4540 AMBASSADOR CAFFERY PKWY SUITE
Mailing Address - Street 2:SUITE A110
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508
Mailing Address - Country:US
Mailing Address - Phone:337-984-1610
Mailing Address - Fax:337-984-2136
Practice Address - Street 1:4540 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:SUITE A110
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6928
Practice Address - Country:US
Practice Address - Phone:337-984-1610
Practice Address - Fax:337-984-2136
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015039R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1301582Medicaid
LAB62854Medicare UPIN
LA1301582Medicaid