Provider Demographics
NPI:1740491208
Name:GBOLOO, GERTRUDE (MD)
Entity type:Individual
Prefix:
First Name:GERTRUDE
Middle Name:
Last Name:GBOLOO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 S PHILIPPE AVE
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-3749
Mailing Address - Country:US
Mailing Address - Phone:225-644-1990
Mailing Address - Fax:225-644-3264
Practice Address - Street 1:2524 S PHILIPPE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-3749
Practice Address - Country:US
Practice Address - Phone:225-644-1990
Practice Address - Fax:225-644-3264
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD202326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine