Provider Demographics
NPI:1801897160
Name:LACOUTURE, JOHN EDWIN JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWIN
Last Name:LACOUTURE
Suffix:JR
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 1:330 BILLINGSLEY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5055
Mailing Address - Country:US
Mailing Address - Phone:704-369-0437
Mailing Address - Fax:704-369-0440
Practice Address - Street 1:330 BILLINGSLEY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5055
Practice Address - Country:US
Practice Address - Phone:704-369-0437
Practice Address - Fax:704-369-0440
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC85033Medicare UPIN
NC2530028AMedicare ID - Type Unspecified