Provider Demographics
NPI:1982607255
Name:FONTENOT, JASON (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FONTENOT
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:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70571-0459
Mailing Address - Country:US
Mailing Address - Phone:337-943-7128
Mailing Address - Fax:
Practice Address - Street 1:133 PARK ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1244
Practice Address - Country:US
Practice Address - Phone:518-483-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021093207L00000X
NY292013207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1952117Medicaid
LA1952117Medicaid
LA5R332Medicare PIN
LA050079492Medicare PIN
LA5R332C203Medicare PIN