MEDICARE: WAYNE DAVID GRAVOIS MD

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	207Q00000X	Family Medicine Physician	016200	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	:	1902806185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAYNE DAVID GRAVOIS MD

Provider Business Mailing Address
First Line	:	3401 NORTH BLVD STE 200
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-3743
Country	:	US
Telephone Number	:	225-381-6620
Fax Number	:	225-819-1179

Provider Business Practice Location Address
First Line	:	3401 NORTH BLVD STE 200
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-3743
Country	:	US
Telephone Number	:	225-381-6620
Fax Number	:	225-819-1179

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	10/03/2019

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