Provider Demographics
NPI:1598729956
Name:BIRMINGHAM, FRED L (OD)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:L
Last Name:BIRMINGHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-1363
Mailing Address - Country:US
Mailing Address - Phone:985-847-0081
Mailing Address - Fax:985-639-9576
Practice Address - Street 1:1173 ROBERT BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2013
Practice Address - Country:US
Practice Address - Phone:985-847-0081
Practice Address - Fax:985-639-9576
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA984-213T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1385042Medicaid
LA1385042Medicaid