Healthcare Provider Details

I. General information

NPI: 1720010606
Provider Name (Legal Business Name): AGRIPPA GAYDEN ROBERT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 09/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15790 PAUL VEGA MD DR
HAMMOND LA
70403-1434
US

IV. Provider business mailing address

PO BOX 2668
HAMMOND LA
70404-2668
US

V. Phone/Fax

Practice location:
  • Phone: 985-230-1682
  • Fax: 985-230-1617
Mailing address:
  • Phone: 985-230-1332
  • Fax: 985-230-1334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.016278
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.016278
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: