Provider Demographics
NPI:1235337346
Name:GREGORY C SAMPOGNARO MD
Entity Type:Organization
Organization Name:GREGORY C SAMPOGNARO MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SAMPOGNARO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-322-7726
Mailing Address - Street 1:2503 BROADMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2987
Mailing Address - Country:US
Mailing Address - Phone:318-322-7726
Mailing Address - Fax:318-322-2614
Practice Address - Street 1:2503 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2987
Practice Address - Country:US
Practice Address - Phone:318-322-7726
Practice Address - Fax:318-322-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11645R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4388289030OtherBLUE CROSS BLUE SHIELD
LA060061109Medicaid
LA060061109OtherRAILROAD MEDICARE
LA060061109OtherRAILROAD MEDICARE