Provider Demographics
NPI:1316986177
Name:BERTUCCINI, THOMAS V (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:V
Last Name:BERTUCCINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 W SAINT MARY BLVD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3568
Mailing Address - Country:US
Mailing Address - Phone:337-235-0933
Mailing Address - Fax:337-269-1328
Practice Address - Street 1:601 W SAINT MARY BLVD
Practice Address - Street 2:SUITE 306
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3568
Practice Address - Country:US
Practice Address - Phone:337-235-0933
Practice Address - Fax:337-269-1328
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA04479R207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1194808Medicaid
LA1194808Medicaid
LAB61322Medicare UPIN