Provider Demographics
NPI:1780675736
Name:SCHELLACK, JON V (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:V
Last Name:SCHELLACK
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8585 PICARDY AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3679
Mailing Address - Country:US
Mailing Address - Phone:225-767-5479
Mailing Address - Fax:225-767-5147
Practice Address - Street 1:8585 PICARDY AVE 310
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3679
Practice Address - Country:US
Practice Address - Phone:225-767-5479
Practice Address - Fax:225-767-5147
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.015733174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366340Medicaid
LAB64148Medicare UPIN
LA52803CC83Medicare ID - Type Unspecified