Provider Demographics
NPI:1639490154
Name:FILLETTE, GARY BRYAN (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:BRYAN
Last Name:FILLETTE
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 1:4501 JACKSON ST EXT STE C
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2555
Mailing Address - Country:US
Mailing Address - Phone:318-484-6850
Mailing Address - Fax:
Practice Address - Street 1:242 W SHAMROCK AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-6439
Practice Address - Country:US
Practice Address - Phone:318-484-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3038482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry