Provider Demographics
NPI:1508283813
Name:FONTENOT, BENJAMIN SCOTT
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:SCOTT
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-0030
Mailing Address - Fax:337-312-0033
Practice Address - Street 1:277 N HIGHWAY 171 STE 8
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5374
Practice Address - Country:US
Practice Address - Phone:337-312-0030
Practice Address - Fax:337-312-0033
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA306762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine