Provider Demographics
NPI:1174549158
Name:CAGNOLATTI, ROBERT DALE (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DALE
Last Name:CAGNOLATTI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 524
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:LA
Mailing Address - Zip Code:71232-0524
Mailing Address - Country:US
Mailing Address - Phone:318-450-0356
Mailing Address - Fax:
Practice Address - Street 1:1812 ROSELAWN AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5434
Practice Address - Country:US
Practice Address - Phone:318-387-9626
Practice Address - Fax:318-325-9425
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA883-328T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1351865Medicaid
LA1351865Medicaid