Provider Demographics
NPI:1205160181
Name:CHRISTIAN A. MAYORGA, MD LLC
Entity type:Organization
Organization Name:CHRISTIAN A. MAYORGA, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAYORGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-305-0063
Mailing Address - Street 1:4228 WILLIAMS BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2270
Mailing Address - Country:US
Mailing Address - Phone:504-305-0063
Mailing Address - Fax:
Practice Address - Street 1:4228 WILLIAMS BLVD
Practice Address - Street 2:STE 201
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2270
Practice Address - Country:US
Practice Address - Phone:504-305-0063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11181R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1662101Medicaid
LA1662101Medicaid
LA5DK60Medicare PIN