Provider Demographics
NPI:1134219264
Name:PROPHETE, LIAUTAUD MORIN SR (DO)
Entity type:Individual
Prefix:DR
First Name:LIAUTAUD
Middle Name:MORIN
Last Name:PROPHETE
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4649
Mailing Address - Country:US
Mailing Address - Phone:209-826-4771
Mailing Address - Fax:209-826-8565
Practice Address - Street 1:502 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4649
Practice Address - Country:US
Practice Address - Phone:209-826-4771
Practice Address - Fax:209-826-8565
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9842207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX98420Medicaid
MS01239531Medicaid
CA00AX98420Medicaid
CA020A98420Medicare PIN