Provider Demographics
NPI:1942316450
Name:BERTUCCI, BRYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:BERTUCCI
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 1:7718 W JUDGE PEREZ DR
Mailing Address - Street 2:
Mailing Address - City:ARABI
Mailing Address - State:LA
Mailing Address - Zip Code:70032-1919
Mailing Address - Country:US
Mailing Address - Phone:504-271-8952
Mailing Address - Fax:504-278-4692
Practice Address - Street 1:843 MILLING AVE
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4442
Practice Address - Country:US
Practice Address - Phone:985-785-5851
Practice Address - Fax:504-278-4692
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015628207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2137689Medicaid
LA015628OtherLA. LICENSE
LA1328031Medicaid
LA1444642Medicaid
LA5M715DS32Medicare PIN
LA5DS32Medicare PIN
LA1328031Medicaid