Provider Demographics
NPI:1437286085
Name:GIDMAN, GORDON GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:GREGORY
Last Name:GIDMAN
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 1:106 FERNEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-8425
Mailing Address - Country:US
Mailing Address - Phone:337-988-0642
Mailing Address - Fax:
Practice Address - Street 1:204 ENERGY PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3816
Practice Address - Country:US
Practice Address - Phone:337-269-0136
Practice Address - Fax:337-233-8525
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012306174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5M407DC78OtherGROUP MEMBER PTAN
LA5DC78OtherNEW GROUP PTAN
LA5M407DC78OtherGROUP MEMBER PTAN
LA421721369OtherEIN
LA721035129OtherEIN