Provider Demographics
NPI:1609874205
Name:LANDRY, GLENN R (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:LANDRY
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 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 313N
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-371-0071
Mailing Address - Fax:504-371-0272
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 313N
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-371-0071
Practice Address - Fax:507-371-0272
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA011421208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4367671004OtherCIGNA
LA1900174OtherUNITED HEALTHCARE
LA1151378Medicaid
LA1021299OtherAETNA
LAD04092Medicare UPIN
LA1900174OtherUNITED HEALTHCARE