Provider Demographics
NPI:1881860088
Name:CROSS GATES PEDIATRICS, INC
Entity Type:Organization
Organization Name:CROSS GATES PEDIATRICS, INC
Other - Org Name:ANGELA SMITH DUTHU, MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:DUTHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-726-0800
Mailing Address - Street 1:3020 GAUSE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4155
Mailing Address - Country:US
Mailing Address - Phone:985-726-0800
Mailing Address - Fax:985-726-0803
Practice Address - Street 1:3020 GAUSE BLVD E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4155
Practice Address - Country:US
Practice Address - Phone:985-726-0800
Practice Address - Fax:985-726-0803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.015652208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1333956Medicaid