Provider Demographics
NPI:1164429171
Name:FUDGE, TOMMY LESTER (MD)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:LESTER
Last Name:FUDGE
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:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-449-4670
Mailing Address - Fax:985-449-2598
Practice Address - Street 1:604 N ACADIA RD
Practice Address - Street 2:SUITE 409
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301
Practice Address - Country:US
Practice Address - Phone:985-449-4670
Practice Address - Fax:985-449-2598
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03512R208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1365475Medicaid
LAP00790563OtherRR MEDICARE
LA51763Medicare PIN
LAP00790563OtherRR MEDICARE