Provider Demographics
NPI:1922040443
Name:TANITA, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:TANITA
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 1:1136A N PINE RD
Mailing Address - Street 2:
Mailing Address - City:OLLA
Mailing Address - State:LA
Mailing Address - Zip Code:71465-4804
Mailing Address - Country:US
Mailing Address - Phone:318-495-3880
Mailing Address - Fax:318-495-3882
Practice Address - Street 1:1136A N PINE RD
Practice Address - Street 2:
Practice Address - City:OLLA
Practice Address - State:LA
Practice Address - Zip Code:71465-4804
Practice Address - Country:US
Practice Address - Phone:318-495-3880
Practice Address - Fax:318-495-3882
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449342Medicaid
LA1054356Medicaid
LAI47835Medicare UPIN
LA1054356Medicaid
LA1449342Medicaid