Provider Demographics
NPI:1386832822
Name:DR JONATHAN J GISCLAIR APMC DBA LAFOURCHE PODIATRY CLINIC
Entity type:Organization
Organization Name:DR JONATHAN J GISCLAIR APMC DBA LAFOURCHE PODIATRY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GISCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:985-325-3668
Mailing Address - Street 1:PO BOX 1759
Mailing Address - Street 2:DEPARTMENT 952
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77251-1759
Mailing Address - Country:US
Mailing Address - Phone:713-554-5304
Mailing Address - Fax:713-554-5324
Practice Address - Street 1:16148 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CUT OFF
Practice Address - State:LA
Practice Address - Zip Code:70345-3511
Practice Address - Country:US
Practice Address - Phone:985-325-3668
Practice Address - Fax:985-325-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD0110213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1131211Medicaid
LA5CS61Medicare PIN
LA1131211Medicaid