Provider Demographics
NPI:1306484290
Name:DR. PATRICK FONTENOT OD, LLC
Entity type:Organization
Organization Name:DR. PATRICK FONTENOT OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:337-625-9075
Mailing Address - Street 1:525 N. CITIES SERVICE HWY WALMART VISION CENTER
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-4107
Mailing Address - Country:US
Mailing Address - Phone:337-625-9075
Mailing Address - Fax:337-625-8105
Practice Address - Street 1:525 N. CITIES SERVICE HWY WALMART VISION CENTER
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-4107
Practice Address - Country:US
Practice Address - Phone:337-625-9075
Practice Address - Fax:337-625-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-11
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2346318Medicaid