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General NPI Number Information
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NPI Number | 1154642015
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Entity Type | Organization
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Legal Business Name | GORDON B MASSENGALE A MEDICAL CORP
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Dates
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Enumeration Date | 06/15/2010
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Last Update Date | 06/15/2010
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Provider Practice Location Address
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Address Line | 111 CHRISTIAN DR
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City | RAYVILLE
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State | LA
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Zip | 71269-3658
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Country | US
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Telephone | 318-728-3263
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Fax | 318-728-3095
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Provider Business Mailing Address
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Address Line | PO BOX 960
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City | RAYVILLE
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State | LA
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Zip | 71269-0960
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Country | US
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Telephone | 318-728-3263
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Fax | 318-728-3095
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Authorized Official
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Title or Position | PRESIDENT
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Name | GORDON B MASSENGALE III
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Credential | M.D.
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Telephone | 318-728-3263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 012197
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License Number State | LA
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