Healthcare Provider Details

I. General information

NPI: 1750387676
Provider Name (Legal Business Name): DONALD SEVERINUS GERVAIS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 NEUROSCIENCE CT
GRAY LA
70359
US

IV. Provider business mailing address

PO BOX 1930
GRAY LA
70359-1930
US

V. Phone/Fax

Practice location:
  • Phone: 985-917-3007
  • Fax: 985-917-3010
Mailing address:
  • Phone: 985-917-3007
  • Fax: 985-917-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD.022617
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: