Provider Demographics
NPI:1487844650
Name:DERSAM, GABRIEL L (MD)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:L
Last Name:DERSAM
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0474
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4704 AMBASSADOR CAFFERY PKWY FL 1
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6908
Practice Address - Country:US
Practice Address - Phone:337-470-5920
Practice Address - Fax:885-431-6868
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103060207X00000X
IL036136684207XP3100X
LAMD.201862207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1033553Medicaid
LA1033553Medicaid
P00475101Medicare PIN