Provider Demographics
NPI:1336380302
Name:ANCELET, JEAN CHARLES-EDOUARD (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:CHARLES-EDOUARD
Last Name:ANCELET
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 1:202 WESTGATE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-2711
Mailing Address - Country:US
Mailing Address - Phone:337-232-1802
Mailing Address - Fax:337-232-1809
Practice Address - Street 1:202 WESTGATE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-2711
Practice Address - Country:US
Practice Address - Phone:337-232-1802
Practice Address - Fax:337-232-1809
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204344208M00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00953567Medicaid
LA1987140Medicaid
LA4Q4667061Medicare PIN