Provider Demographics
NPI:1235298050
Name:MAYORGA, CHRISTIAN ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:ANTONIO
Last Name:MAYORGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4228 WILLIAMS BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2270
Mailing Address - Country:US
Mailing Address - Phone:504-305-0063
Mailing Address - Fax:504-305-2366
Practice Address - Street 1:4228 WILLIAMS BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2270
Practice Address - Country:US
Practice Address - Phone:504-305-0063
Practice Address - Fax:504-305-2366
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11181R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1662101Medicaid
LA1662101Medicaid
LA5W291Medicare ID - Type Unspecified