Provider Demographics
NPI:1346256096
Name:GILLEN, GRANT (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:GILLEN
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 1:2816 KINGSTON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062-4995
Mailing Address - Country:US
Mailing Address - Phone:504-408-0804
Mailing Address - Fax:
Practice Address - Street 1:2816 KINGSTON ST
Practice Address - Street 2:SUITE C
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-4995
Practice Address - Country:US
Practice Address - Phone:504-408-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026743207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology