Provider Demographics
NPI:1346209236
Name:COULLARD, GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:COULLARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2710
Mailing Address - Country:US
Mailing Address - Phone:225-654-1061
Mailing Address - Fax:225-654-0791
Practice Address - Street 1:2421 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2710
Practice Address - Country:US
Practice Address - Phone:225-654-1061
Practice Address - Fax:225-654-0791
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA683333T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1135411Medicaid
LA48718Medicare PIN
LA1135411Medicaid