Basic Information
| Provider Information | |||||||||
| NPI: | 1740263052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVESTER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 TULANE AVE | ||||||||
| Address2: | HC 71 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049885800 | ||||||||
| FaxNumber: | 5049887616 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 TULANE AVE | ||||||||
| Address2: | HC 71 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049885800 | ||||||||
| FaxNumber: | 5049887616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 08/14/2007 | ||||||||
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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 | 2085R0202X | 200101 | LA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1628085 | 05 | LA | MEDICAID |