Provider Demographics
NPI:1871590711
Name:GAMMAGE, COY W JR (M D)
Entity type:Individual
Prefix:
First Name:COY
Middle Name:W
Last Name:GAMMAGE
Suffix:JR
Gender:M
Credentials:M D
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:318-966-1970
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:411 CALYPSO ST STE 200A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7551
Practice Address - Country:US
Practice Address - Phone:318-966-1970
Practice Address - Fax:318-966-1971
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021331207RH0003X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1976652Medicaid
LA830005032OtherRRMC
LAG45766Medicare UPIN
LA1976652Medicaid