Provider Demographics
NPI:1811947153
Name:SEAL, GREGORY SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:SCOTT
Last Name:SEAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10191 TRAILRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7651
Mailing Address - Country:US
Mailing Address - Phone:318-222-6226
Mailing Address - Fax:318-221-8526
Practice Address - Street 1:3341 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2149
Practice Address - Country:US
Practice Address - Phone:318-219-4167
Practice Address - Fax:318-219-4834
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021174174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1465682Medicaid
LA1465682Medicaid
LA4J069Medicare ID - Type Unspecified