Provider Demographics
NPI:1396745907
Name:ALLEN, MARYELLON (MD)
Entity type:Individual
Prefix:DR
First Name:MARYELLON
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6322 HIGHWAY 182 E
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70380-2038
Mailing Address - Country:US
Mailing Address - Phone:985-702-1220
Mailing Address - Fax:985-702-9715
Practice Address - Street 1:6322 HIGHWAY 182 E
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-2038
Practice Address - Country:US
Practice Address - Phone:985-702-1220
Practice Address - Fax:985-702-9715
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15521R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1464368Medicaid
LA4J243CN25Medicare PIN
LAI21838Medicare UPIN