Healthcare Provider Details

I. General information

NPI: 1962467191
Provider Name (Legal Business Name): MONTY ANTHONY GLORIOSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 03/07/2023
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 HOUMA BLVD STE 300
METAIRIE LA
70006-4203
US

IV. Provider business mailing address

3601 HOUMA BLVD STE 402
METAIRIE LA
70006-4310
US

V. Phone/Fax

Practice location:
  • Phone: 504-264-5142
  • Fax:
Mailing address:
  • Phone: 504-503-5123
  • Fax: 504-503-5129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number021194
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: