Provider Demographics
NPI:1124091574
Name:DANTAGNAN, FREDERICK W IV (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:W
Last Name:DANTAGNAN
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4228 HOUMA BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-3000
Mailing Address - Country:US
Mailing Address - Phone:504-889-5250
Mailing Address - Fax:504-889-5288
Practice Address - Street 1:4228 HOUMA BLVD
Practice Address - Street 2:STE 400
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-3000
Practice Address - Country:US
Practice Address - Phone:504-889-5250
Practice Address - Fax:504-889-5288
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA024747207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1575208Medicaid
LA4E268DH01OtherMEDICARE PTAN
LAH62703Medicare UPIN
LA1575208Medicaid