Healthcare Provider Details

I. General information

NPI: 1255331443
Provider Name (Legal Business Name): GORDON B. MASSENGALE III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CHRISTIAN DR
RAYVILLE LA
71269-3658
US

IV. Provider business mailing address

PO BOX 960
RAYVILLE LA
71269-0960
US

V. Phone/Fax

Practice location:
  • Phone: 318-728-3263
  • Fax: 318-728-3095
Mailing address:
  • Phone: 318-728-3263
  • Fax: 318-728-3095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number012197
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: