Provider Demographics
NPI:1790876019
Name:DESTREHAN MEDICAL CLINIC
Entity Type:Organization
Organization Name:DESTREHAN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHEMMALE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYAKRISHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-785-2045
Mailing Address - Street 1:12604 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DESTREHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70047-5306
Mailing Address - Country:US
Mailing Address - Phone:985-764-0439
Mailing Address - Fax:985-725-1464
Practice Address - Street 1:12604 RIVER RD
Practice Address - Street 2:
Practice Address - City:DESTREHAN
Practice Address - State:LA
Practice Address - Zip Code:70047-5306
Practice Address - Country:US
Practice Address - Phone:985-764-0439
Practice Address - Fax:985-725-1464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1798703Medicaid
LAB89019Medicare UPIN
LA57184Medicare ID - Type Unspecified