Provider Demographics
NPI:1003930280
Name:FARGASON, DONNA BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:BRIAN
Last Name:FARGASON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9311A BLUEBONNET BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2806
Mailing Address - Country:US
Mailing Address - Phone:225-769-5551
Mailing Address - Fax:225-769-5583
Practice Address - Street 1:9311A BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2806
Practice Address - Country:US
Practice Address - Phone:225-769-5551
Practice Address - Fax:225-769-5583
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0230782084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1484059Medicaid