Provider Demographics
NPI:1053365130
Name:ELDRIDGE, JOEL GLEN (DO)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:GLEN
Last Name:ELDRIDGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 HIGHWAY 577
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-5367
Mailing Address - Country:US
Mailing Address - Phone:318-722-3759
Mailing Address - Fax:318-435-0406
Practice Address - Street 1:233 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-2431
Practice Address - Country:US
Practice Address - Phone:318-435-8363
Practice Address - Fax:318-435-0406
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08682R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1918296Medicaid
LA1918296Medicaid
LAE24218Medicare UPIN