Healthcare Provider Details

I. General information

NPI: 1255837886
Provider Name (Legal Business Name): LUKE BURKETT FONDREN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 N MCKENZIE ST
FOLEY AL
36535-2247
US

IV. Provider business mailing address

7856 WESTSIDE PARK DR STE H
MOBILE AL
36695-8539
US

V. Phone/Fax

Practice location:
  • Phone: 251-949-3400
  • Fax:
Mailing address:
  • Phone: 251-450-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDO.2036
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: