Provider Demographics
NPI:1376689323
Name:GAYNOR, RICHARD GENE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GENE
Last Name:GAYNOR
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 1:2320 DRUSILLA LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1495
Mailing Address - Country:US
Mailing Address - Phone:225-924-7500
Mailing Address - Fax:225-924-7501
Practice Address - Street 1:2320 DRUSILLA LN
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1495
Practice Address - Country:US
Practice Address - Phone:225-924-7500
Practice Address - Fax:225-924-7501
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.015433261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA720957732OtherCHAMPUS
LA1309001Medicaid
LA05756OtherBLUE CROSS
LAB62763Medicare UPIN
LA1309001Medicaid