Provider Demographics
NPI:1336166255
Name:SAN PEDRO, GERARDO SANTOS (MD)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:SANTOS
Last Name:SAN PEDRO
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 1:2400 HOSPITAL DR
Mailing Address - Street 2:STE 340
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2387
Mailing Address - Country:US
Mailing Address - Phone:318-747-2277
Mailing Address - Fax:318-747-2217
Practice Address - Street 1:2400 HOSPITAL DR STE 340
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2387
Practice Address - Country:US
Practice Address - Phone:318-747-2277
Practice Address - Fax:318-747-2217
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11657R207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1680877Medicaid
LA1680877Medicaid
LA5W757F600Medicare ID - Type Unspecified