Provider Demographics
NPI:1962467191
Name:GLORIOSO, MONTY ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:MONTY
Middle Name:ANTHONY
Last Name:GLORIOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 HOUMA BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-4310
Mailing Address - Country:US
Mailing Address - Phone:504-503-5123
Mailing Address - Fax:504-503-5129
Practice Address - Street 1:3530 HOUMA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-4203
Practice Address - Country:US
Practice Address - Phone:504-264-5142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021194207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
021194OtherSTATE LIC #
LA1983764Medicaid
99046OtherCOVENTRY
LA1445509Medicaid
2704219001OtherCIGNA
F6413OtherBSBS AUTH #
4555509OtherAETNA
4555509OtherAETNA
021194OtherSTATE LIC #
5U217Medicare ID - Type Unspecified
99046OtherCOVENTRY
BG3602213OtherDEA
4555509OtherAETNA