Provider Demographics
NPI:1831129105
Name:HEROMAN, GREGORY MIDDLETON (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MIDDLETON
Last Name:HEROMAN
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 1:500 RUE DE LA VIE AVE
Mailing Address - Street 2:SUITE 411
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-5126
Mailing Address - Country:US
Mailing Address - Phone:225-751-4488
Mailing Address - Fax:225-751-1001
Practice Address - Street 1:500 RUE DE LA VIE AVE
Practice Address - Street 2:SUITE 411
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-5126
Practice Address - Country:US
Practice Address - Phone:225-751-4488
Practice Address - Fax:225-751-1001
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012327174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1191876Medicaid
LAB61417Medicare UPIN
LA5L651Medicare ID - Type Unspecified