Provider Demographics
NPI:1841309556
Name:CORDOVA, JAIME MIGUEL (MD)
Entity type:Individual
Prefix:MR
First Name:JAIME
Middle Name:MIGUEL
Last Name:CORDOVA
Suffix:
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 1:1442 E BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517
Mailing Address - Country:US
Mailing Address - Phone:337-332-2428
Mailing Address - Fax:337-332-6977
Practice Address - Street 1:1442 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517
Practice Address - Country:US
Practice Address - Phone:337-332-2428
Practice Address - Fax:337-332-6977
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022843207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1490725Medicaid
LA5Y343Medicare ID - Type Unspecified
G45552Medicare UPIN