Provider Demographics
NPI:1639162290
Name:LORD, GREGORY D (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:LORD
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 1:301 W FERTITTA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4665
Mailing Address - Country:US
Mailing Address - Phone:337-238-0167
Mailing Address - Fax:337-238-0574
Practice Address - Street 1:301 W FERTITTA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4665
Practice Address - Country:US
Practice Address - Phone:337-238-0167
Practice Address - Fax:337-238-0574
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
LA016350208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1322750Medicaid
B64504Medicare UPIN
LA1322750Medicaid