Provider Demographics
NPI:1720302730
Name:DAUTERIVE, EDWARD WEEKS III (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:WEEKS
Last Name:DAUTERIVE
Suffix:III
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 1:58515 PEARL ACRES RD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5423
Mailing Address - Country:US
Mailing Address - Phone:985-641-8982
Mailing Address - Fax:
Practice Address - Street 1:58515 PEARL ACRES RD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5423
Practice Address - Country:US
Practice Address - Phone:985-641-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD 205027207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2106406Medicaid