Provider Demographics
NPI:1003810474
Name:BERTOLINO, GERARD ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:ANTHONY
Last Name:BERTOLINO
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 1:1990 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-7055
Mailing Address - Country:US
Mailing Address - Phone:985-868-9300
Mailing Address - Fax:985-851-0053
Practice Address - Street 1:1990 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-7055
Practice Address - Country:US
Practice Address - Phone:985-868-9300
Practice Address - Fax:985-851-0053
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6772207ZP0102X
LAMD.017641207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220009432OtherRAILROAD M/C-NEPG
LA1773387Medicaid
TX220018816OtherRAILROAD MEDICARE
TX220018816OtherRAILROAD MEDICARE
TX220009432OtherRAILROAD M/C-NEPG
LA1773387Medicaid
TXF00666Medicare UPIN