Provider Demographics
NPI:1275538993
Name:FONTENOT, EUGENE (MD12)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:MD12
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 4290
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70606-4290
Mailing Address - Country:US
Mailing Address - Phone:337-474-2056
Mailing Address - Fax:337-477-9334
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-474-2056
Practice Address - Fax:337-477-9334
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014734207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1320196Medicaid
LA51941C423Medicare ID - Type Unspecified
LA1320196Medicaid