Provider Demographics
NPI:1568562742
Name:GOMBAKO WITHERSPOON, LOUISE ANN (MD)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:ANN
Last Name:GOMBAKO WITHERSPOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:LOUISE
Other - Middle Name:ANN
Other - Last Name:GOMBAKO WITHERSPOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1015 APACHE DR
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-6133
Mailing Address - Country:US
Mailing Address - Phone:601-810-8889
Mailing Address - Fax:
Practice Address - Street 1:777 LOWNDES HILL RD BLDG 1
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2101
Practice Address - Country:US
Practice Address - Phone:864-908-3530
Practice Address - Fax:864-967-2289
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19007207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1043621OtherLOUISIANA MEDICAID
MS03886877Medicaid
MS03886877Medicaid
MS1G0000686Medicare ID - Type Unspecified