Provider Demographics
NPI:1710286794
Name:PONTCHARTRAIN CANCER CENTER
Entity Type:Organization
Organization Name:PONTCHARTRAIN CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.,/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:OUBRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:985-419-0025
Mailing Address - Street 1:15752 MEDICAL ARTS PLAZA
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1446
Mailing Address - Country:US
Mailing Address - Phone:985-419-0025
Mailing Address - Fax:985-875-0035
Practice Address - Street 1:120 LAKEVIEW CIR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7512
Practice Address - Country:US
Practice Address - Phone:985-875-1202
Practice Address - Fax:985-875-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22330174400000X
LA203749174400000X
LARN083847-AP04197174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1478377Medicaid
LA1883883Medicaid
LA1665878Medicaid
LAP89300Medicare UPIN
LA1478377Medicaid
LA1883883Medicaid