Provider Demographics
NPI:1366468084
Name:MIRE, LOUIS GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:GLEN
Last Name:MIRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4205
Mailing Address - Country:US
Mailing Address - Phone:337-261-6690
Mailing Address - Fax:337-261-6662
Practice Address - Street 1:2390 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4205
Practice Address - Country:US
Practice Address - Phone:337-261-6690
Practice Address - Fax:337-261-6662
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12202207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1197386Medicaid
LA380001653OtherRAILROAD MEDICARE
LA380001653OtherRAILROAD MEDICARE
LA1197386Medicaid