Basic Information
| Provider Information | |||||||||
| NPI: | 1750383949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEJIA | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 578 | ||||||||
| Address2: | |||||||||
| City: | BOGALUSA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704290578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857358022 | ||||||||
| FaxNumber: | 9857358023 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 AVENUE F | ||||||||
| Address2: | |||||||||
| City: | BOGALUSA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704274340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857358022 | ||||||||
| FaxNumber: | 9857358023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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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 | 207RC0000X | 08620R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00119070 | 05 | MS | MEDICAID | 1908703 | 05 | LA | MEDICAID |