Basic Information
| Provider Information | |||||||||
| NPI: | 1760703763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASRA | ||||||||
| FirstName: | GURJOT | ||||||||
| MiddleName: | KAUR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122539 DEPT 2539 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753122539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942772 | ||||||||
| FaxNumber: | 3374942928 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374808994 | ||||||||
| FaxNumber: | 3374808993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2010 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | MD207980 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 2452266 | 05 | LA | MEDICAID | MD.207980 | 01 | LA | LSBME | OTHER |