Basic Information
Provider Information | |||||||||
NPI: | 1508807405 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DRAGON | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 107 S MILITARY RD STE 1 | ||||||||
Address2: |   | ||||||||
City: | SLIDELL | ||||||||
State: | LA | ||||||||
PostalCode: | 704614158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9856412866 | ||||||||
FaxNumber: | 9856417998 | ||||||||
Practice Location | |||||||||
Address1: | 85 WHISPERWOOD BLVD | ||||||||
Address2: |   | ||||||||
City: | SLIDELL | ||||||||
State: | LA | ||||||||
PostalCode: | 704581136 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9856412866 | ||||||||
FaxNumber: | 9857815395 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2006 | ||||||||
LastUpdateDate: | 02/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 04523 | LA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | G7147 | 01 | LA | BLUECROSS BLUESHIELD | OTHER |