Provider Demographics
NPI:1306014667
Name:TASSIN, ROBERT L JR (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:TASSIN
Suffix:JR
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 1:119 WHITE STORK DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-3207
Mailing Address - Country:US
Mailing Address - Phone:985-290-4026
Mailing Address - Fax:985-646-3898
Practice Address - Street 1:119 WHITE STORK DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-3207
Practice Address - Country:US
Practice Address - Phone:985-290-4026
Practice Address - Fax:985-646-3898
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121254Medicaid
LA1350214Medicaid
LAMD.017359OtherLSBME
LA13367OtherLA CDS LICENSE
MS16877OtherMS MEDICAL LICENSE
MS16877OtherMS MEDICAL LICENSE
MS00121254Medicaid
LA249981YH3UMedicare PIN