Basic Information
| Provider Information | |||||||||
| NPI: | 1659418325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | KYLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255260011 | ||||||||
| FaxNumber: | 2257659196 | ||||||||
| Practice Location | |||||||||
| Address1: | 18901 GREENWELL SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | GREENWELL SPRINGS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707394836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259249985 | ||||||||
| FaxNumber: | 2259240884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11621R | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11621R | 01 | LA | STATE LICENSE | OTHER | 1695467 | 05 | LA | MEDICAID | 72-0537628 | 01 | LA | TAX ID | OTHER |