Basic Information
| Provider Information | |||||||||
| NPI: | 1104055706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARDOZO-KELLOGG | ||||||||
| FirstName: | DANIELA | ||||||||
| MiddleName: | PAOLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARDOZO | ||||||||
| OtherFirstName: | DANIELA | ||||||||
| OtherMiddleName: | PAOLA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 139 VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | DENHAM SPRINGS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707268905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257545280 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1514 JEFFERSON HWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701212429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048424000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2009 | ||||||||
| LastUpdateDate: | 05/23/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 6066 | NE | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD.205582 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03739389 | 05 | MS | MEDICAID | 2303236 | 05 | LA | MEDICAID |