Provider Demographics
NPI:1679779979
Name:OGHLAKIAN, GERARD OHANNES (MD)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:OHANNES
Last Name:OGHLAKIAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2115 S FREMONT AVE STE 4300
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2232
Mailing Address - Country:US
Mailing Address - Phone:417-820-3911
Mailing Address - Fax:417-820-3924
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:STE 4300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-3911
Practice Address - Fax:417-820-3924
Is Sole Proprietor?:No
Enumeration Date:2007-06-23
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2011006602207RC0000X, 207RA0001X
NJTRAINING LICENSE207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00954926OtherRR MCR
AR188964001Medicaid
MO1679779979Medicaid
MO431560263OtherTRICARE
AR188964001Medicaid
MO1679779979Medicaid