Basic Information
| Provider Information | |||||||||
| NPI: | 1659364495 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOSEPH | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 INDIANA AVENUE | ||||||||
| Address2: | |||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700654605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9853071600 | ||||||||
| FaxNumber: | 5045753691 | ||||||||
| Practice Location | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | |||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855800 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 09/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 023712 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1579483 | 05 | LA | MEDICAID | 1486965 | 05 | LA | MEDICAID |