Provider Demographics
NPI:1861567950
Name:STACK, GERALD E (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:E
Last Name:STACK
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 1:8786 GOODWOOD BLVD
Mailing Address - Street 2:STE. 106
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7917
Mailing Address - Country:US
Mailing Address - Phone:225-924-0244
Mailing Address - Fax:225-924-0340
Practice Address - Street 1:8786 GOODWOOD BLVD
Practice Address - Street 2:STE. 106
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7917
Practice Address - Country:US
Practice Address - Phone:225-924-0244
Practice Address - Fax:225-924-0340
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD016009174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1338591Medicaid
LAB61425Medicare UPIN
LA1338591Medicaid