Provider Demographics
NPI:1992855282
Name:KOUBICEK, CARMEN ENID (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:ENID
Last Name:KOUBICEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 ATTAKAPAS DR
Mailing Address - Street 2:SUITE 401 K
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570
Mailing Address - Country:US
Mailing Address - Phone:337-407-0084
Mailing Address - Fax:337-407-0094
Practice Address - Street 1:1270 ATTAKAPAS DR
Practice Address - Street 2:SUITE 401 K
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570
Practice Address - Country:US
Practice Address - Phone:337-407-0084
Practice Address - Fax:337-407-0084
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13448R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13448ROtherSTATE MED LICENSE
LA1900972OtherCLIA
LA1565911Medicaid
F56899Medicare UPIN