Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 020594 | LA |
N | 208600000X | Surgeon | 020594 | LA |
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 020594 | LA |
NPI | 1083685770 |
---|---|
Provider Name | Jared Gilmore III |
First Address | Thibodaux, LA 70302-5478 |
Second Address | Thibodaux, LA 70301-4897 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2006 |
Last Update Date | 08/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1902560 | (05) | LA |
E81900 | (02) | LA |