Provider Demographics
NPI:1295059202
Name:LANDRY, JARED (MD)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:LANDRY
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 1:119 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-1607
Mailing Address - Country:US
Mailing Address - Phone:337-802-2639
Mailing Address - Fax:
Practice Address - Street 1:602 N ACADIA RD
Practice Address - Street 2:ANESTHESIA DEPT.
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4847
Practice Address - Country:US
Practice Address - Phone:985-438-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.206604207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA300093737OtherRAILROAD MEDICARE PTAN
LA2106961Medicaid
LA371656YKG2Medicare PIN