Provider Demographics
NPI:1063557551
Name:GILCREASE, EDWARD G
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:G
Last Name:GILCREASE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-4334
Mailing Address - Country:US
Mailing Address - Phone:318-330-9070
Mailing Address - Fax:318-387-4343
Practice Address - Street 1:1010 S VIENNA ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5832
Practice Address - Country:US
Practice Address - Phone:318-255-9433
Practice Address - Fax:318-255-2425
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1398-528T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1475815Medicaid
LA1475815Medicaid
LA4B312Medicare PIN