Basic Information
| Provider Information | |||||||||
| NPI: | 1639259153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOVRETICH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | OTTO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8230 SUMMA AVE STE C | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257570552 | ||||||||
| FaxNumber: | 2257639997 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 WOMANS WAY | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708175100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259248264 | ||||||||
| FaxNumber: | 2259248242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 06/05/2015 | ||||||||
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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 | 019094 | LA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1910732 | 05 | LA | MEDICAID |