Provider Demographics
NPI:1760472443
Name:CULPEPPER, ROBERT C
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:CULPEPPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 JACKSON STREET EXT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3007
Mailing Address - Country:US
Mailing Address - Phone:318-487-9860
Mailing Address - Fax:318-473-9244
Practice Address - Street 1:3916 JACKSON STREET EXT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3007
Practice Address - Country:US
Practice Address - Phone:318-487-9860
Practice Address - Fax:318-473-9244
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL006995174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1051144Medicaid
LA51184Medicare ID - Type Unspecified
LA1051144Medicaid