Provider Demographics
NPI:1467746628
Name:GRAVOIS, ERIC JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JOHN
Last Name:GRAVOIS
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 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-447-5500
Mailing Address - Fax:985-449-2535
Practice Address - Street 1:3928 HIGHWAY 70 S
Practice Address - Street 2:
Practice Address - City:PIERRE PART
Practice Address - State:LA
Practice Address - Zip Code:70339-4460
Practice Address - Country:US
Practice Address - Phone:985-252-1111
Practice Address - Fax:985-252-1400
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD206882207Q00000X
FL16251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2368838Medicaid
LA356734ZHH2Medicare PIN