Provider Demographics
NPI:1417941162
Name:GALLIEN, JEROME (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:GALLIEN
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:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-1128
Mailing Address - Country:US
Mailing Address - Phone:337-824-4403
Mailing Address - Fax:337-824-9731
Practice Address - Street 1:1634 ELTON RD
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-3614
Practice Address - Country:US
Practice Address - Phone:337-616-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0161932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1913961Medicaid
LA5N461Medicare ID - Type Unspecified
LA1913961Medicaid