Healthcare Provider Details

I. General information

NPI: 1871590711
Provider Name (Legal Business Name): COY W. GAMMAGE JR. M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CALYPSO ST STE 200A
MONROE LA
71201-7551
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-1970
  • Fax: 318-966-1971
Mailing address:
  • Phone: 318-966-1970
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number021331
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number021331
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: