Provider Demographics
NPI:1346744570
Name:FONTENOT, JEFFREY DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DOUGLAS
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:PO BOX 53092
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3092
Mailing Address - Country:US
Mailing Address - Phone:337-289-8933
Mailing Address - Fax:
Practice Address - Street 1:1122 SOUTH BERNARD RD
Practice Address - Street 2:SUITE B
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518
Practice Address - Country:US
Practice Address - Phone:337-289-8933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA328521207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine