Provider Demographics
NPI:1851393078
Name:MEHAFFIE, DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:MEHAFFIE
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:PO BOX 6039
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70174-6039
Mailing Address - Country:US
Mailing Address - Phone:504-393-2775
Mailing Address - Fax:504-393-2744
Practice Address - Street 1:148 WALL BLVD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7107
Practice Address - Country:US
Practice Address - Phone:504-393-2775
Practice Address - Fax:504-393-2744
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1545929Medicaid
LA5E853Medicare PIN
LA1545929Medicaid