Provider Demographics
NPI:1770634628
Name:MOUTON, GERALD WADE (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:WADE
Last Name:MOUTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 122539
Mailing Address - Street 2:DEPT 2539
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2539
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2750 ASTER ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8824
Practice Address - Country:US
Practice Address - Phone:337-480-8900
Practice Address - Fax:337-480-8901
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1357880Medicaid
LA52011DD92OtherMEDICARE
LAMEDICARE LEGACYOther52011CB93
LA$$$$$$$$$GOtherBCBS
LAB63530Medicare UPIN
LA1357880Medicaid