Provider Demographics
NPI:1689736241
Name:DELATTE, BRIAN JOSEPH (PD)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOSEPH
Last Name:DELATTE
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 FENCE ROW ST
Mailing Address - Street 2:
Mailing Address - City:SCHRIEVER
Mailing Address - State:LA
Mailing Address - Zip Code:70395-4320
Mailing Address - Country:US
Mailing Address - Phone:985-447-9630
Mailing Address - Fax:985-873-8541
Practice Address - Street 1:7869 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4461
Practice Address - Country:US
Practice Address - Phone:985-873-8526
Practice Address - Fax:985-873-8541
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11097183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1906099OtherNABP
LA1233510Medicaid