Provider Demographics
NPI:1538151451
Name:DAUTERIVE, EDWARD W JR (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:W
Last Name:DAUTERIVE
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 1:1100 ANDRE ST. STE. 101
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563-2159
Mailing Address - Country:US
Mailing Address - Phone:337-369-9309
Mailing Address - Fax:337-365-8455
Practice Address - Street 1:1100 ANDRE ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2159
Practice Address - Country:US
Practice Address - Phone:337-369-9309
Practice Address - Fax:337-365-8455
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014729208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1339334Medicaid
LA1339334Medicaid
LA51840DE05Medicare PIN
LA51840Medicare ID - Type Unspecified