Provider Demographics
NPI:1740310754
Name:COMBETTA, JEFFREY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOHN
Last Name:COMBETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2104 LOOP RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-3338
Mailing Address - Country:US
Mailing Address - Phone:318-435-4571
Mailing Address - Fax:318-435-7458
Practice Address - Street 1:2104 LOOP RD
Practice Address - Street 2:SUITE C
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3338
Practice Address - Country:US
Practice Address - Phone:318-435-4571
Practice Address - Fax:318-435-7458
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA203014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1501174Medicaid
12125071OtherCAQH
LAMD.203014OtherLICENSE