Provider Demographics
NPI:1104879253
Name:IRRA, THEODORE A (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:A
Last Name:IRRA
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 1:3434 HOUMA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-4278
Mailing Address - Country:US
Mailing Address - Phone:504-458-6061
Mailing Address - Fax:504-866-0206
Practice Address - Street 1:3434 HOUMA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-4200
Practice Address - Country:US
Practice Address - Phone:504-458-6061
Practice Address - Fax:504-866-0206
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11701R207P00000X
LAMD.08928R208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1977276Medicaid
LAG74301Medicare UPIN