Provider Demographics
NPI:1639255995
Name:MAMMEN, JOSHUA P (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:P
Last Name:MAMMEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 NORTH EASTERN AVE.
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526
Mailing Address - Country:US
Mailing Address - Phone:337-788-2216
Mailing Address - Fax:337-783-9407
Practice Address - Street 1:713 NORTH EASTERN AVE.
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-3856
Practice Address - Country:US
Practice Address - Phone:337-788-2216
Practice Address - Fax:337-783-9407
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05428R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1320501Medicaid
LA53254Medicare ID - Type Unspecified
LA1320501Medicaid