Provider Demographics
NPI:1912190646
Name:LOUISIANA DERMATOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:LOUISIANA DERMATOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:IMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-927-5663
Mailing Address - Street 1:1014 W ST.CLARE BOULEVARD
Mailing Address - Street 2:SUITE 1040
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737
Mailing Address - Country:US
Mailing Address - Phone:225-743-2090
Mailing Address - Fax:225-743-2093
Practice Address - Street 1:1014 W. ST. CLARE BOULEVARD
Practice Address - Street 2:SUITE 1040
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737
Practice Address - Country:US
Practice Address - Phone:225-743-2090
Practice Address - Fax:225-743-2093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty