Provider Demographics
NPI:1902894637
Name:DEIDRE L STELLY MD APMLLC
Entity Type:Organization
Organization Name:DEIDRE L STELLY MD APMLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEIDRE
Authorized Official - Middle Name:L
Authorized Official - Last Name:STELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-261-5151
Mailing Address - Street 1:112 CHAMPAGNE BLVD
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-3852
Mailing Address - Country:US
Mailing Address - Phone:337-332-2242
Mailing Address - Fax:
Practice Address - Street 1:112 CHAMPAGNE BLVD
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3852
Practice Address - Country:US
Practice Address - Phone:337-261-5151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1443077Medicaid
LADC3527Medicare PIN
LA5CN36Medicare PIN