Provider Demographics
NPI:1093761645
Name:HARGRODER, TY GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:GLENN
Last Name:HARGRODER
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:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:CHURCH POINT
Mailing Address - State:LA
Mailing Address - Zip Code:70525-0407
Mailing Address - Country:US
Mailing Address - Phone:337-684-5232
Mailing Address - Fax:337-684-3434
Practice Address - Street 1:3501 HIGHWAY 190 STE X
Practice Address - Street 2:
Practice Address - City:EUNICE
Practice Address - State:LA
Practice Address - Zip Code:70535-5129
Practice Address - Country:US
Practice Address - Phone:337-580-7544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020601207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA678856OtherAETNA
LA1398501Medicaid
LA72-1190076OtherIRS
LA080166458OtherRR MEDICARE