Healthcare Provider Details

I. General information

NPI: 1649213596
Provider Name (Legal Business Name): GARY JOSEPH BIRDSALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W 112TH ST
CUT OFF LA
70345-3628
US

IV. Provider business mailing address

102 W 112TH ST
CUT OFF LA
70345-3628
US

V. Phone/Fax

Practice location:
  • Phone: 985-632-5222
  • Fax: 985-632-4222
Mailing address:
  • Phone: 985-632-5222
  • Fax: 985-632-4222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number017642
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: