Provider Demographics
NPI:1558386631
Name:GOMES, GLENN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:MARK
Last Name:GOMES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10310 THE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70836-6455
Mailing Address - Country:US
Mailing Address - Phone:225-761-5200
Mailing Address - Fax:225-761-5711
Practice Address - Street 1:10310 THE GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70836-6455
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-761-5711
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015674207RC0200X
LA15674207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1312037Medicaid
5R641Medicare ID - Type Unspecified
LA1312037Medicaid