Provider Demographics
NPI:1609994714
Name:TRUDY H SANSON MD A MEDICAL CORP
Entity Type:Organization
Organization Name:TRUDY H SANSON MD A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:H
Authorized Official - Last Name:SANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-387-0641
Mailing Address - Street 1:102 THOMAS RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7366
Mailing Address - Country:US
Mailing Address - Phone:318-387-0641
Mailing Address - Fax:318-387-0645
Practice Address - Street 1:102 THOMAS RD
Practice Address - Street 2:SUITE 206
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7366
Practice Address - Country:US
Practice Address - Phone:318-387-0641
Practice Address - Fax:318-387-0645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017870207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1399922Medicaid
LA5CD53Medicare PIN
LA1399922Medicaid