Provider Demographics
NPI:1487185955
Name:PAUL GUILBAULT MD, FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:PAUL GUILBAULT MD, FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GUILBAULT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:985-630-9618
Mailing Address - Street 1:521 ASBURY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:985-630-9618
Mailing Address - Fax:985-231-7010
Practice Address - Street 1:521 ASBURY DRIVE
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471
Practice Address - Country:US
Practice Address - Phone:985-630-9618
Practice Address - Fax:985-231-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-25
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12621-R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1541907Medicaid
LA1541907Medicaid