Provider Demographics
NPI:1588875017
Name:RICHARD, TREVOR C (MD)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:C
Last Name:RICHARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2647 S SAINT ELIZABETH BLVD
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-5021
Mailing Address - Country:US
Mailing Address - Phone:225-647-8511
Mailing Address - Fax:225-644-5213
Practice Address - Street 1:2647 S SAINT ELIZABETH BLVD
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5021
Practice Address - Country:US
Practice Address - Phone:225-647-8511
Practice Address - Fax:225-644-5213
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202291208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07946Medicaid
LA1079464Medicaid
LA1079464Medicaid