Provider Demographics
NPI:1285741777
Name:FONTENOT, HERBERT JERREL (MD)
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:JERREL
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 678308
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8308
Mailing Address - Country:US
Mailing Address - Phone:800-897-6169
Mailing Address - Fax:601-936-0686
Practice Address - Street 1:1275 GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5539
Practice Address - Country:US
Practice Address - Phone:318-322-1339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018863207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00119325OtherMEDICARE RAILROAD
LAP00119325Medicaid
LAP00119325Medicaid
LAE58304Medicare UPIN