Provider Demographics
NPI:1407097470
Name:MOORE, LAUREN GILLIS (MD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:GILLIS
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8490 PICARDY AVE
Mailing Address - Street 2:BLDG 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3731
Mailing Address - Country:US
Mailing Address - Phone:225-237-1754
Mailing Address - Fax:225-237-1722
Practice Address - Street 1:13960 FLORIDA BOULEVARD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:LA
Practice Address - Zip Code:70754
Practice Address - Country:US
Practice Address - Phone:225-686-0158
Practice Address - Fax:225-686-9965
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.203904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4R220B116OtherMEDICARE PTAN
LA1945325Medicaid