Provider Demographics
NPI:1386734887
Name:FONTENOT, EUDICE E (MD)
Entity type:Individual
Prefix:
First Name:EUDICE
Middle Name:E
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 1:1 CHILDREN'S WAY, MAIL SLOT 512-3
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3510
Mailing Address - Country:US
Mailing Address - Phone:501-364-1479
Mailing Address - Fax:501-364-3667
Practice Address - Street 1:1 CHILDRENS WAY
Practice Address - Street 2:MAIL SLOT 512-3
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-1479
Practice Address - Fax:501-364-3667
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-20372080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR124535001Medicaid
AR5AG336884Medicare PIN
AR124535001Medicaid
B89483Medicare UPIN