Provider Demographics
NPI:1891852984
Name:GUILLORY, CLINT C (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:C
Last Name:GUILLORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:130 DESIARD STREET
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-9997
Practice Address - Street 1:2408 BROADMOOR BOULEVARD
Practice Address - Street 2:SUITE 2
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-807-7875
Practice Address - Fax:318-812-9997
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2012-01-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA015565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1397261Medicaid
LA1351199Medicaid
LAB62598Medicare UPIN
B62598Medicare UPIN
LA1397261Medicaid
4F914Medicare PIN