Provider Demographics
NPI:1962679647
Name:VAN M ARDOIN, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:VAN M ARDOIN, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ARDOIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-876-6980
Mailing Address - Street 1:603 DUNN ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4707
Mailing Address - Country:US
Mailing Address - Phone:985-876-6980
Mailing Address - Fax:985-876-6975
Practice Address - Street 1:603 DUNN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4707
Practice Address - Country:US
Practice Address - Phone:985-876-6980
Practice Address - Fax:985-876-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1146170Medicaid
LA1146170Medicaid