Provider Demographics
NPI:1477653673
Name:GALLEGOS, ELIZABETH DENISE (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DENISE
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:DENISE
Other - Last Name:GALLEGOS-FARHAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-769-7979
Mailing Address - Fax:225-769-4228
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4375
Practice Address - Country:US
Practice Address - Phone:225-769-9797
Practice Address - Fax:225-769-4228
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG069197207R00000X
FLME0070878207R00000X
LA13364R207U00000X
MS16977207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1568741Medicaid
LA4E554Medicare ID - Type Unspecified
LA1568741Medicaid