Provider Demographics
NPI:1942385703
Name:FAUTHEREE, GREGORY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LEE
Last Name:FAUTHEREE
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:PO BOX 98509
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-9509
Mailing Address - Country:US
Mailing Address - Phone:225-769-2200
Mailing Address - Fax:225-768-2185
Practice Address - Street 1:10101 PARK ROWE AVE STE 200
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:225-769-2200
Practice Address - Fax:225-768-2185
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.203804207T00000X
FLTRN6823207T00000X
FLME105666207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2112562Medicaid
FL001635000Medicaid
LA2112562Medicaid