Provider Demographics
NPI:1427199207
Name:FONTENOT, THOMAS GLENN (MD,)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GLENN
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 1:417 E. LINCOLN RD.
Mailing Address - Street 2:
Mailing Address - City:VILLE PLATTE
Mailing Address - State:LA
Mailing Address - Zip Code:70586-3431
Mailing Address - Country:US
Mailing Address - Phone:337-363-7744
Mailing Address - Fax:337-363-5166
Practice Address - Street 1:417 E. LINCOLN RD
Practice Address - Street 2:
Practice Address - City:VILLE PLATTE
Practice Address - State:LA
Practice Address - Zip Code:70586-3431
Practice Address - Country:US
Practice Address - Phone:337-363-7744
Practice Address - Fax:337-363-5166
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1368296Medicaid
LA1368296Medicaid
LAB64574Medicare UPIN