Provider Demographics
NPI:1538128285
Name:FANDAL, FREDDIE JOSEPH JR (MD)
Entity Type:Individual
Prefix:
First Name:FREDDIE
Middle Name:JOSEPH
Last Name:FANDAL
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:PO BOX 1338
Mailing Address - Street 2:
Mailing Address - City:PORT BARRE
Mailing Address - State:LA
Mailing Address - Zip Code:70577
Mailing Address - Country:US
Mailing Address - Phone:337-585-7898
Mailing Address - Fax:337-585-7899
Practice Address - Street 1:17695 HWY 190
Practice Address - Street 2:
Practice Address - City:PORT BARRE
Practice Address - State:LA
Practice Address - Zip Code:70577
Practice Address - Country:US
Practice Address - Phone:337-585-7898
Practice Address - Fax:337-585-7899
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA080164292OtherRR MEDICARE
LA1430692Medicaid
LA1538128285Medicare PIN
LA1430692Medicaid