Provider Demographics
NPI:1700082682
Name:TRAVIS, BRETT ROBERT (MD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:ROBERT
Last Name:TRAVIS
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:PO BOX 2668
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2668
Mailing Address - Country:US
Mailing Address - Phone:985-230-6700
Mailing Address - Fax:985-230-1528
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-230-6700
Practice Address - Fax:985-230-1528
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2016172085B0100X, 2085R0202X
LA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09202849Medicaid
LA1508195Medicaid
LA296708YH3UMedicare PIN
LA1508195Medicaid
MS09202849Medicaid