Provider Demographics
NPI:1144436015
Name:MAPLEWOOD FAMILY MEDICINE CLINIC
Entity type:Organization
Organization Name:MAPLEWOOD FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANG
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-625-5459
Mailing Address - Street 1:3702 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-6302
Mailing Address - Country:US
Mailing Address - Phone:337-625-5459
Mailing Address - Fax:337-626-2045
Practice Address - Street 1:3702 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-6302
Practice Address - Country:US
Practice Address - Phone:337-625-5459
Practice Address - Fax:337-626-2045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4K238BD22Medicare PIN
LA4K872BD22Medicare PIN
LA4K238Medicare PIN
LA5BD22Medicare PIN