Basic Information
| Provider Information | |||||||||
| NPI: | 1013579150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMERSON | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | LANE | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1747 IMPERIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706055362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377217236 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1747 IMPERIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706055362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377217236 | ||||||||
| FaxNumber: | 3377217237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2019 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | PO9593 | LA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 213ES0103X | 322786 | LA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.