Provider Demographics
NPI:1578723599
Name:GRIDLEY, ASAHEL L (MD)
Entity Type:Individual
Prefix:
First Name:ASAHEL
Middle Name:L
Last Name:GRIDLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:1850 GAUSE BLVD E
Practice Address - Street 2:SUITE 202
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5442
Practice Address - Country:US
Practice Address - Phone:985-639-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.203729208600000X
MS24075208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1106089Medicaid
MS03839737Medicaid
LA368745YH3UMedicare PIN