Provider Demographics
NPI:1255331443
Name:MASSENGALE, GORDON B III (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:B
Last Name:MASSENGALE
Suffix:III
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 960
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-0960
Mailing Address - Country:US
Mailing Address - Phone:318-728-3263
Mailing Address - Fax:318-728-3095
Practice Address - Street 1:111 CHRISTIAN DR
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-3658
Practice Address - Country:US
Practice Address - Phone:318-728-3263
Practice Address - Fax:318-728-3095
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA53443Medicare ID - Type Unspecified
LAC67544Medicare UPIN