Provider Demographics
NPI:1780048587
Name:EDWARDS, ELISE FONTENOT (MD)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:FONTENOT
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:MARIE
Other - Last Name:FONTENOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2300 HOSPITAL DR STE 120
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2193
Mailing Address - Country:US
Mailing Address - Phone:318-212-7982
Mailing Address - Fax:318-212-7989
Practice Address - Street 1:2300 HOSPITAL DR STE 120
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2193
Practice Address - Country:US
Practice Address - Phone:318-212-7982
Practice Address - Fax:318-212-7989
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312926208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program