Provider Demographics
NPI:1679674758
Name:EBELING, ROBERT L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:EBELING
Suffix:JR
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:PO BOX 3027
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71210-3027
Mailing Address - Country:US
Mailing Address - Phone:318-327-1917
Mailing Address - Fax:318-327-1938
Practice Address - Street 1:411 CALYPSO ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7506
Practice Address - Country:US
Practice Address - Phone:318-327-1900
Practice Address - Fax:318-327-1901
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.08207R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1394351Medicaid
LA5K712Medicare ID - Type Unspecified
LA1394351Medicaid