Provider Demographics
NPI:1649213596
Name:BIRDSALL, GARY JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JOSEPH
Last Name:BIRDSALL
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 1:102 W 112TH ST
Mailing Address - Street 2:
Mailing Address - City:CUT OFF
Mailing Address - State:LA
Mailing Address - Zip Code:70345-3628
Mailing Address - Country:US
Mailing Address - Phone:985-632-5222
Mailing Address - Fax:985-632-4222
Practice Address - Street 1:102 W 112TH ST
Practice Address - Street 2:
Practice Address - City:CUT OFF
Practice Address - State:LA
Practice Address - Zip Code:70345-3628
Practice Address - Country:US
Practice Address - Phone:985-632-5222
Practice Address - Fax:985-632-4222
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366145Medicaid
LA5W983Medicare ID - Type Unspecified
LA1366145Medicaid