Provider Demographics
NPI:1013949619
Name:PALO, MATTI W JR (MD)
Entity Type:Individual
Prefix:
First Name:MATTI
Middle Name:W
Last Name:PALO
Suffix:JR
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:
Practice Address - Street 1:70411 HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8103
Practice Address - Country:US
Practice Address - Phone:985-400-5566
Practice Address - Fax:985-400-5560
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.025221207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04233229Medicaid
LA1572713Medicaid
LA4F072Medicare PIN
LA1572713Medicaid
LA4F0727061Medicare PIN
MS04233229Medicaid