NPIMap

Organization Active NPI

Destrehan Medical Clinic

  • Primary Care Clinic/Center
  • Destrehan, LA
National Provider Identifier
1790876019
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
DESTREHAN MEDICAL CLINIC
Practice address
12604 River Rd
Destrehan, LA 70047-5306
Phone
(985) 764-0439
Fax
(985) 725-1464
NPI assigned
Sep 28, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Chemmale Jayakrishnan
Title
President/Doctor
Phone
(985) 785-2045

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X LA Primary

Addresses

Primary practice location

12604 River Rd
Destrehan, LA 70047-5306

Mailing address

12604 River Rd
Destrehan, LA 70047-5306
Phone (985) 764-0439

Other identifiers 1

IdentifierTypeStateIssuer
1798703MedicaidLA

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159401600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1790876019",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12604 RIVER RD",
            "city": "DESTREHAN",
            "state": "LA",
            "postal_code": "700475306",
            "telephone_number": "985-764-0439",
            "fax_number": "985-725-1464"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12604 RIVER RD",
            "city": "DESTREHAN",
            "state": "LA",
            "postal_code": "700475306",
            "telephone_number": "985-764-0439",
            "fax_number": "985-725-1464"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DESTREHAN MEDICAL CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-28",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "JAYAKRISHNAN",
        "authorized_official_first_name": "CHEMMALE",
        "authorized_official_title_or_position": "PRESIDENT/DOCTOR",
        "authorized_official_telephone_number": "985-785-2045",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "LA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1798703",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Destrehan, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.