Provider Demographics
NPI:1770587248
Name:MATERNAL FETAL MEDICINE OF ACADIANA
Entity type:Organization
Organization Name:MATERNAL FETAL MEDICINE OF ACADIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:K
Authorized Official - Last Name:DIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-942-1151
Mailing Address - Street 1:PO BOX 51742
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1742
Mailing Address - Country:US
Mailing Address - Phone:337-593-9099
Mailing Address - Fax:337-948-4392
Practice Address - Street 1:105 CORPORATE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3850
Practice Address - Country:US
Practice Address - Phone:337-593-9099
Practice Address - Fax:337-948-4392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-11
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11220R207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447757Medicaid
LA5CT09Medicare PIN