Provider Demographics
NPI:1104993708
Name:MOOREHEAD, MYRON ERNEST II (MD)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:ERNEST
Last Name:MOOREHEAD
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MYRON
Other - Middle Name:E
Other - Last Name:MOOREHEAD MD APMC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:200 W ESPLANADE AVE
Mailing Address - Street 2:SUITE 311
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2474
Mailing Address - Country:US
Mailing Address - Phone:504-467-0770
Mailing Address - Fax:504-467-0791
Practice Address - Street 1:200 W ESPLANADE AVE
Practice Address - Street 2:SUITE 311
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2474
Practice Address - Country:US
Practice Address - Phone:504-467-0770
Practice Address - Fax:504-467-0791
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD4222R207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA092522606OtherCONTROLLED SUBSTANCE LIC
LAB60947Medicare UPIN
B60947Medicare UPIN