Provider Demographics
NPI:1083772883
Name:GEORGE, BRYANT GERARD SR (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:GERARD
Last Name:GEORGE
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 62600
Mailing Address - Street 2:DEPT 1453
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70162-2600
Mailing Address - Country:US
Mailing Address - Phone:337-436-7560
Mailing Address - Fax:337-433-9861
Practice Address - Street 1:1611 FOSTER ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5815
Practice Address - Country:US
Practice Address - Phone:337-436-7560
Practice Address - Fax:337-433-9861
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA018940207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1378356Medicaid
D66126Medicare UPIN
LA54896Medicare PIN