Provider Demographics
NPI:1750467007
Name:GERVAIS, WENDY SUDDETH (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:SUDDETH
Last Name:GERVAIS
Suffix:
Gender:F
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 4051
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-4051
Mailing Address - Country:US
Mailing Address - Phone:985-917-3007
Mailing Address - Fax:985-851-7526
Practice Address - Street 1:128 NEUROSCIENCE CT
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:LA
Practice Address - Zip Code:70359-5209
Practice Address - Country:US
Practice Address - Phone:985-917-3007
Practice Address - Fax:985-917-3010
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.0238872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA48599Medicaid
LA4A156F903Medicare PIN