Provider Demographics
NPI:1417934373
Name:FONTENOT, REED A JR (MD)
Entity Type:Individual
Prefix:
First Name:REED
Middle Name:A
Last Name:FONTENOT
Suffix:JR
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 1:2016 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7828
Mailing Address - Country:US
Mailing Address - Phone:337-477-8861
Mailing Address - Fax:337-477-3092
Practice Address - Street 1:2016 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7828
Practice Address - Country:US
Practice Address - Phone:337-477-8861
Practice Address - Fax:337-477-3092
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010029208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1110744Medicaid
LA05242OtherBCBS
LA05242OtherBCBS
B89473Medicare UPIN