MEDICARE: DONALD SEVERINUS GERVAIS JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	MD.022617	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750387676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD SEVERINUS GERVAIS JR. M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1930
Second Line	:
City	:	GRAY
State	:	LA
Zip	:	70359-1930
Country	:	US
Telephone Number	:	985-917-3007
Fax Number	:	985-917-3010

Provider Business Practice Location Address
First Line	:	128 NEUROSCIENCE CT
Second Line	:
City	:	GRAY
State	:	LA
Zip	:	70359
Country	:	US
Telephone Number	:	985-917-3007
Fax Number	:	985-917-3010

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	12/11/2018

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