Provider Demographics
NPI:1013985530
Name:FONTENOT, MATTHEW SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SHANE
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 53092
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3092
Mailing Address - Country:US
Mailing Address - Phone:337-289-8978
Mailing Address - Fax:337-289-8970
Practice Address - Street 1:1214 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2621
Practice Address - Country:US
Practice Address - Phone:337-289-7927
Practice Address - Fax:337-289-7935
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2009-08-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA024987207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4J90JCM76Medicare ID - Type UnspecifiedGROUP 5CM76