Provider Demographics
NPI:1710044862
Name:SEBASTIAN, IRENE MARY (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:MARY
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-2957
Mailing Address - Country:US
Mailing Address - Phone:504-838-9804
Mailing Address - Fax:504-838-9806
Practice Address - Street 1:401 VETERANS MEMORIAL BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70005-2957
Practice Address - Country:US
Practice Address - Phone:504-838-9804
Practice Address - Fax:504-838-9806
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12655R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1541318Medicaid
LA1541318Medicaid
LA5A644Medicare ID - Type Unspecified