Provider Demographics
NPI:1295938892
Name:MCNULTY, MICHAEL JESSE IV (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JESSE
Last Name:MCNULTY
Suffix:IV
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 1:2731 NAPOLEON AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115
Mailing Address - Country:US
Mailing Address - Phone:504-897-6351
Mailing Address - Fax:504-899-7317
Practice Address - Street 1:3800 HOUMA BOULEVARD
Practice Address - Street 2:SUITE 200
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006
Practice Address - Country:US
Practice Address - Phone:504-897-6351
Practice Address - Fax:504-899-7317
Is Sole Proprietor?:No
Enumeration Date:2007-06-09
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD203982207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP2-0017768OtherINSTITUTIONAL PERMIT