Provider Demographics
NPI:1598043143
Name:GASPARD, BRYAN A (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:A
Last Name:GASPARD
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:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-5955
Mailing Address - Fax:601-200-5943
Practice Address - Street 1:971 LAKELAND DR STE 1250
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4609
Practice Address - Country:US
Practice Address - Phone:601-200-5955
Practice Address - Fax:601-200-5939
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31518207T00000X
MS21587207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2189662Medicaid
MS04383309Medicaid
LA2189662Medicaid
MS302I146194Medicare PIN
MS04383309Medicaid