Provider Demographics
NPI:1710917414
Name:GLOWACKI, GREGORY LYON (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LYON
Last Name:GLOWACKI
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 53247
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3247
Mailing Address - Country:US
Mailing Address - Phone:337-289-8780
Mailing Address - Fax:337-571-0010
Practice Address - Street 1:1555 GARY DR STE A
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3448
Practice Address - Country:US
Practice Address - Phone:337-909-2474
Practice Address - Fax:337-909-2479
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015143208000000X
LAMD.015143207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1321010Medicaid
LA1321010Medicaid
LAB61668Medicare UPIN