Basic Information
| Provider Information | |||||||||
| NPI: | 1487844650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERSAM | ||||||||
| FirstName: | GABRIEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255260002 | ||||||||
| FaxNumber: | 2257659196 | ||||||||
| Practice Location | |||||||||
| Address1: | 4704 AMBASSADOR CAFFERY PKWY FL 1 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705086908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374705920 | ||||||||
| FaxNumber: | 8854316868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 103060 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XP3100X | 036136684 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XP3100X | MD.201862 | LA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1033553 | 05 | LA | MEDICAID |