Provider Demographics
NPI:1750320172
Name:FAY, MARK DAVID (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:FAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7827
Mailing Address - Country:US
Mailing Address - Phone:225-408-7990
Mailing Address - Fax:225-408-7989
Practice Address - Street 1:8080 BLUEBONNET BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-7827
Practice Address - Country:US
Practice Address - Phone:225-408-7990
Practice Address - Fax:225-408-7989
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04438225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C799C811Medicare ID - Type UnspecifiedPHYSICAL THERPAY