Healthcare Provider Details

I. General information

NPI: 1720195290
Provider Name (Legal Business Name): DANA ANGELLE FAKOURI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8040 GOODWOOD BLVD
BATON ROUGE LA
70806-7631
US

IV. Provider business mailing address

8040 GOODWOOD BLVD
BATON ROUGE LA
70806-7631
US

V. Phone/Fax

Practice location:
  • Phone: 225-928-0867
  • Fax: 225-928-1948
Mailing address:
  • Phone: 225-928-0867
  • Fax: 225-928-1948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number020840
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: