Provider Demographics
NPI:1962559740
Name:PEDIATRIC CARDIOLOGY OF SOUTHWEST LOUISIANA, LLC
Entity type:Organization
Organization Name:PEDIATRIC CARDIOLOGY OF SOUTHWEST LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUDAR
Authorized Official - Middle Name:M
Authorized Official - Last Name:KATTASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-562-2293
Mailing Address - Street 1:2005 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4139
Mailing Address - Country:US
Mailing Address - Phone:337-562-2293
Mailing Address - Fax:337-562-1469
Practice Address - Street 1:2005 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4139
Practice Address - Country:US
Practice Address - Phone:337-562-2293
Practice Address - Fax:337-562-1469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.12869R2080P0202X
LAMD.2030752080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty