Provider Demographics
NPI:1487615662
Name:MURPHY, JACK P (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:MURPHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:P
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:398 BELLE TERRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-2435
Mailing Address - Country:US
Mailing Address - Phone:985-652-7191
Mailing Address - Fax:985-652-2911
Practice Address - Street 1:398 BELLE TERRE BLVD
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-2435
Practice Address - Country:US
Practice Address - Phone:985-652-7191
Practice Address - Fax:985-652-2911
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0-10905207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1145351Medicaid
LA1145351Medicaid
LAB65599Medicare UPIN