Provider Demographics
NPI:1033316310
Name:FONTENOT, BENNETT (MD)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 FERNRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5444
Mailing Address - Country:US
Mailing Address - Phone:337-504-6271
Mailing Address - Fax:
Practice Address - Street 1:900 E SAINT MARY BLVD STE 104
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2378
Practice Address - Country:US
Practice Address - Phone:337-504-3640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL30088208600000X
LAMD.205820208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA437739YJRAOtherPLASTIC AND RECONSTRUCTIVE SURGERY
LA2400541Medicaid