Provider Demographics
NPI:1952398356
Name:ALLEN, GREGORY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:ALLEN
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:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-0129
Mailing Address - Country:US
Mailing Address - Phone:985-386-6198
Mailing Address - Fax:985-386-6223
Practice Address - Street 1:105 E OAK ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-2619
Practice Address - Country:US
Practice Address - Phone:985-386-6198
Practice Address - Fax:985-386-6223
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAL018162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1950009Medicaid
LAB63544Medicare UPIN
LA52030Medicare PIN