Basic Information
| Provider Information | |||||||||
| NPI: | 1174506182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODCHAUX | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | BURTON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 974150 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753974150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375939500 | ||||||||
| FaxNumber: | 3375930909 | ||||||||
| Practice Location | |||||||||
| Address1: | 856 KALISTE SALOOM RD STE B | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705084395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375939500 | ||||||||
| FaxNumber: | 3375930909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 11/09/2009 | ||||||||
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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 | 011929 | LA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1164798 | 05 | LA | MEDICAID |