Provider Demographics
NPI:1467669887
Name:RISENER, FREDERICK S JR (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:S
Last Name:RISENER
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 1:1281 W TUNNEL BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2794
Mailing Address - Country:US
Mailing Address - Phone:985-876-2321
Mailing Address - Fax:985-917-0800
Practice Address - Street 1:1281 W TUNNEL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2794
Practice Address - Country:US
Practice Address - Phone:985-876-2321
Practice Address - Fax:985-917-0800
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10130R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1979619Medicaid
LA4F565Medicare ID - Type Unspecified
LA1979619Medicaid