Provider Demographics
NPI:1063411361
Name:DAFTARY, MAHMOUD (MD)
Entity type:Individual
Prefix:DR
First Name:MAHMOUD
Middle Name:
Last Name:DAFTARY
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 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:2750 GAUSE BLVD. EAST
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461
Practice Address - Country:US
Practice Address - Phone:985-639-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04535R174400000X
LAMD.04535R208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122909Medicaid
LA1329444Medicaid
LAP00396221OtherRAILROAD MEDICARE
LA$$$$$$$$$AOtherBLUE CROSS
MS00122909Medicaid
LA517456629Medicare PIN
LAP00396221OtherRAILROAD MEDICARE
LA51745Medicare PIN