Basic Information
| Provider Information | |||||||||
| NPI: | 1225419211 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMANGUE | ||||||||
| FirstName: | BRANT | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 JEFFERSON HWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701212429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048424000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704615520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856465189 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2015 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | LL38466 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 310574 | LA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.