Provider Demographics
NPI:1790705036
Name:TEDESCO, VICTOR E IV (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:E
Last Name:TEDESCO
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VICTOR
Other - Middle Name:E
Other - Last Name:TEDESCO
Other - Suffix:IV
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5000 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:PROVINCE BLDG. 14-A
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6984
Mailing Address - Country:US
Mailing Address - Phone:337-234-7779
Mailing Address - Fax:337-235-7246
Practice Address - Street 1:155 HOSPITAL DR STE 201
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2852
Practice Address - Country:US
Practice Address - Phone:337-289-7999
Practice Address - Fax:337-289-7998
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1385794Medicaid
LA020027313OtherRR MEDICARE
LAE15130Medicare UPIN
LA1385794Medicaid