Provider Demographics
NPI:1821187873
Name:MAHON-DERI, BRENDA M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:M
Last Name:MAHON-DERI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 8TH ST
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-1623
Mailing Address - Country:US
Mailing Address - Phone:504-833-7770
Mailing Address - Fax:504-833-7796
Practice Address - Street 1:3223 8TH ST
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-1623
Practice Address - Country:US
Practice Address - Phone:504-833-7770
Practice Address - Fax:504-833-7796
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09859R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1491888Medicaid
LA5A044Medicare ID - Type Unspecified
LA1491888Medicaid