Provider Demographics
NPI:1437147352
Name:GILLMORE, DIANA L (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:GILLMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:985 ROBERT BLVD
Mailing Address - Street 2:#103
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2063
Mailing Address - Country:US
Mailing Address - Phone:985-646-1884
Mailing Address - Fax:985-646-1885
Practice Address - Street 1:985 ROBERT BLVD
Practice Address - Street 2:#103
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2063
Practice Address - Country:US
Practice Address - Phone:985-646-1884
Practice Address - Fax:985-646-1885
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA05478R208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA721142319OtherTAX ID
LA1363367Medicaid
LA39700OtherBCBS
B62985Medicare UPIN
LA39700OtherBCBS