Provider Demographics
NPI:1841233475
Name:HERCULES, PETER L (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:L
Last Name:HERCULES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:427 HWY 51 NORTH
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2600
Practice Address - Country:US
Practice Address - Phone:601-892-2149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293334207P00000X, 207Q00000X
MS16013207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126873Medicaid
MSG53114Medicare UPIN