Provider Demographics
NPI:1851679849
Name:DIANA L. GILLMORE, M.D.,L.L.C.
Entity Type:Organization
Organization Name:DIANA L. GILLMORE, M.D.,L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GILLMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-646-1884
Mailing Address - Street 1:985 ROBERT BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2063
Mailing Address - Country:US
Mailing Address - Phone:985-646-1884
Mailing Address - Fax:985-646-1885
Practice Address - Street 1:985 ROBERT BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2063
Practice Address - Country:US
Practice Address - Phone:985-646-1884
Practice Address - Fax:985-646-1885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05478R208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA39700OtherBLUE CROSS BLUE SHIELD
MS0015875Medicaid
LA1363367Medicaid
LA51337Medicare UPIN