1033316310 NPI number — BENNETT FONTENOT M.D.

Table of content: BENNETT FONTENOT M.D. (NPI 1033316310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033316310 NPI number — BENNETT FONTENOT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTENOT
Provider First Name:
BENNETT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033316310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 FERNRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-5444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-504-6271
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 E SAINT MARY BLVD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-2378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-504-3640
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  LL30088 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: MD.205820 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 437739YJRA . This is a "PLASTIC AND RECONSTRUCTIVE SURGERY" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 2400541 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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