Provider Demographics
NPI:1902821861
Name:DETIEGE, PIERRE G (MD)
Entity Type:Individual
Prefix:DR
First Name:PIERRE
Middle Name:G
Last Name:DETIEGE
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 1:1816 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-2314
Mailing Address - Country:US
Mailing Address - Phone:504-366-7638
Mailing Address - Fax:504-366-1029
Practice Address - Street 1:1816 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-2314
Practice Address - Country:US
Practice Address - Phone:504-366-7638
Practice Address - Fax:504-366-1029
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070246L207P00000X
LAMD201664207P00000X
FLME81323207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H27039Medicare UPIN