Provider Demographics
NPI:1700051133
Name:FUQUA, JASON BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:BRIAN
Last Name:FUQUA
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 1:920 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-3425
Mailing Address - Country:US
Mailing Address - Phone:337-528-7472
Mailing Address - Fax:337-528-7457
Practice Address - Street 1:920 1ST AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-3425
Practice Address - Country:US
Practice Address - Phone:337-528-7472
Practice Address - Fax:337-528-7457
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-27
Last Update Date:2012-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine