Provider Demographics
NPI:1063462679
Name:FARGASON, CRAYTON (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAYTON
Middle Name:
Last Name:FARGASON
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 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 4000
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-766-7441
Mailing Address - Fax:225-766-7597
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 4000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-766-7441
Practice Address - Fax:225-766-7597
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009603207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1126004Medicaid
LA180015625OtherRAILROAD MEDICARE
LA1126004Medicaid
LAB63270Medicare UPIN
LA51689B969Medicare PIN