Provider Demographics
NPI:1154642015
Name:GORDON B MASSENGALE A MEDICAL CORP
Entity type:Organization
Organization Name:GORDON B MASSENGALE A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:B
Authorized Official - Last Name:MASSENGALE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:318-728-3263
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-0960
Mailing Address - Country:US
Mailing Address - Phone:318-728-3263
Mailing Address - Fax:318-728-3095
Practice Address - Street 1:111 CHRISTIAN DR
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-3658
Practice Address - Country:US
Practice Address - Phone:318-728-3263
Practice Address - Fax:318-728-3095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1160717Medicaid
LA1160717Medicaid
LA53443Medicare PIN