Provider Demographics
NPI:1710163340
Name:STACEY W MAYEAUX MD LLC
Entity Type:Organization
Organization Name:STACEY W MAYEAUX MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MAYEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-678-3755
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70571-0008
Mailing Address - Country:US
Mailing Address - Phone:337-678-3755
Mailing Address - Fax:337-678-3757
Practice Address - Street 1:519 E PRUDHOMME ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6499
Practice Address - Country:US
Practice Address - Phone:337-678-3755
Practice Address - Fax:337-678-3757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1013986892OtherNPI
LA1423271Medicaid
LAH45590Medicare UPIN