Provider Demographics
NPI:1083685770
Name:GILMORE, JARED III (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:GILMORE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5478
Mailing Address - Street 2:STE 409
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-449-4670
Mailing Address - Fax:985-449-2598
Practice Address - Street 1:604 N ACADIA RD
Practice Address - Street 2:STE 409
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4897
Practice Address - Country:US
Practice Address - Phone:985-449-4670
Practice Address - Fax:985-449-2598
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA020594208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1902560Medicaid
LA5N467D516Medicare PIN
LA1902560Medicaid
LAP00628513Medicare PIN