Provider Demographics
NPI:1013089424
Name:BERAULT, GREGORY L (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:BERAULT
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 1:2365 GAUSE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4142
Mailing Address - Country:US
Mailing Address - Phone:985-643-1194
Mailing Address - Fax:985-643-8869
Practice Address - Street 1:2365 GAUSE BLVD E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4142
Practice Address - Country:US
Practice Address - Phone:985-643-1194
Practice Address - Fax:985-643-8869
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025452174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1574805Medicaid
LA4F325Medicare PIN
LAH96891Medicare UPIN