Healthcare Provider Details

I. General information

NPI: 1477653673
Provider Name (Legal Business Name): ELIZABETH DENISE GALLEGOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH DENISE GALLEGOS-FARHAT M.D.

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 HENNESSY BLVD
BATON ROUGE LA
70808-4375
US

IV. Provider business mailing address

7777 HENNESSY BLVD SUITE 110
BATON ROUGE LA
70808-4300
US

V. Phone/Fax

Practice location:
  • Phone: 225-769-9797
  • Fax: 225-769-4228
Mailing address:
  • Phone: 225-769-7979
  • Fax: 225-769-4228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG069197
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0070878
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number13364R
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number16977
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: