Provider Demographics
NPI:1891719985
Name:GENOVESE, CHARLES RAYMOND JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RAYMOND
Last Name:GENOVESE
Suffix:JR
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 1:312 EAST RAILROAD AVENUE
Mailing Address - Street 2:P.O. BOX 969
Mailing Address - City:INDEPENDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:70443
Mailing Address - Country:US
Mailing Address - Phone:985-878-4183
Mailing Address - Fax:985-878-3830
Practice Address - Street 1:312 EAST RAILROAD AVENUE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443
Practice Address - Country:US
Practice Address - Phone:985-878-4183
Practice Address - Fax:985-878-3830
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1335681Medicaid
LA1335681Medicaid
LA51082Medicare ID - Type Unspecified