Provider Demographics
NPI:1255334314
Name:CULASSO, MIGUEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:A
Last Name:CULASSO
Suffix:
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:225-526-0001
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:1520 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458
Practice Address - Country:US
Practice Address - Phone:985-646-0945
Practice Address - Fax:985-643-8510
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2022-07-21
Deactivation Date:2005-05-23
Deactivation Code:
Reactivation Date:2005-05-24
Provider Licenses
StateLicense IDTaxonomies
LA013032207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1341657Medicaid
LA51226Medicare PIN
LA51226Medicare ID - Type Unspecified
LA1341657Medicaid