Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 207966 | LA |
NPI | 1003128463 |
---|---|
Provider Name | Dr. Joel E Perdomo |
First Address | Slidell, LA 70460-4130 |
Second Address | Slidell, LA 70460-4130 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2010 |
Last Update Date | 23/02/2017 |