Provider Demographics
NPI:1114217189
Name:MEDAURA, JUAN (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:MEDAURA
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 1:3600 PRYTANIA ST STE 35
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3678
Mailing Address - Country:US
Mailing Address - Phone:504-897-8412
Mailing Address - Fax:504-249-5311
Practice Address - Street 1:3525 PRYTANIA ST STE 402
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-3585
Practice Address - Country:US
Practice Address - Phone:504-648-2520
Practice Address - Fax:504-897-2939
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA330645207RN0300X
MS24487207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2582445Medicaid
MSP01788687OtherRAILROAD MEDICARE
MS07624070Medicaid