Provider Demographics
NPI:1790773430
Name:PRIDE PLAZA MEDICAL LLC
Entity Type:Organization
Organization Name:PRIDE PLAZA MEDICAL LLC
Other - Org Name:STEPHENS JOHNNY J MEMBER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MWAKITAWA
Authorized Official - Last Name:MWATIBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:337-233-2115
Mailing Address - Street 1:850 N PIERCE STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-2848
Mailing Address - Country:US
Mailing Address - Phone:337-233-2115
Mailing Address - Fax:337-237-9075
Practice Address - Street 1:850 N PIERCE STREET
Practice Address - Street 2:SUITE D
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-2848
Practice Address - Country:US
Practice Address - Phone:337-233-2115
Practice Address - Fax:337-237-9075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1443522Medicaid
LA1443522Medicaid
LACK4908Medicare PIN