Provider Demographics
NPI:1508807405
Name:DRAGON, GARY JOSEPH JR (PT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:JOSEPH
Last Name:DRAGON
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:107 S MILITARY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4158
Mailing Address - Country:US
Mailing Address - Phone:985-641-2866
Mailing Address - Fax:985-641-7998
Practice Address - Street 1:85 WHISPERWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-1136
Practice Address - Country:US
Practice Address - Phone:985-641-2866
Practice Address - Fax:985-781-5395
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAG7147OtherBLUECROSS BLUESHIELD
LAG7147OtherBLUECROSS BLUESHIELD