Provider Demographics
NPI:1760692081
Name:FORTIER, ALAN B JR (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:B
Last Name:FORTIER
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 1:804 S ACADIA RD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4850
Mailing Address - Country:US
Mailing Address - Phone:985-446-2680
Mailing Address - Fax:985-447-2528
Practice Address - Street 1:804 S ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4850
Practice Address - Country:US
Practice Address - Phone:985-446-2680
Practice Address - Fax:985-447-2528
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1092185Medicaid
LA4N1776796Medicare PIN