Provider Demographics
NPI:1174629299
Name:MAZZANTI, GARY BERNARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:BERNARD
Last Name:MAZZANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:701 JORDAN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4660
Mailing Address - Country:US
Mailing Address - Phone:318-221-6700
Mailing Address - Fax:318-221-6701
Practice Address - Street 1:701 JORDAN ST
Practice Address - Street 2:SUITE A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4660
Practice Address - Country:US
Practice Address - Phone:318-221-6700
Practice Address - Fax:318-221-6701
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2009-12-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAMD020779207PE0005X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1399256Medicaid
LAE38105Medicare UPIN
LA5H633Medicare ID - Type Unspecified