Provider Demographics
NPI:1336249168
Name:MORVANT, DALE J (MD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:J
Last Name:MORVANT
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 1:100 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461
Mailing Address - Country:US
Mailing Address - Phone:225-929-7210
Mailing Address - Fax:225-930-7524
Practice Address - Street 1:8212 KELWOOD AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806
Practice Address - Country:US
Practice Address - Phone:225-929-7210
Practice Address - Fax:225-930-7524
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014777207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1335576Medicaid
LA54113Medicare ID - Type UnspecifiedMEDICARE IND NUM
LA1335576Medicaid