Provider Demographics
NPI:1083724538
Name:JOHN PHIL FONTENOT, LLC
Entity Type:Organization
Organization Name:JOHN PHIL FONTENOT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-468-5150
Mailing Address - Street 1:1415 7TH ST
Mailing Address - Street 2:SUITE K
Mailing Address - City:MAMOU
Mailing Address - State:LA
Mailing Address - Zip Code:70554-2269
Mailing Address - Country:US
Mailing Address - Phone:337-468-5150
Mailing Address - Fax:337-468-5155
Practice Address - Street 1:1415 7TH ST
Practice Address - Street 2:SUITE K
Practice Address - City:MAMOU
Practice Address - State:LA
Practice Address - Zip Code:70554-2269
Practice Address - Country:US
Practice Address - Phone:337-468-5150
Practice Address - Fax:337-468-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200868207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1066125Medicaid