Healthcare Provider Details

I. General information

NPI: 1982603254
Provider Name (Legal Business Name): MICHAEL TODD FONTENOT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8595 PICARDY AVE STE 305
BATON ROUGE LA
70809-3670
US

IV. Provider business mailing address

8490 PICARDY AVE BLDG 200
BATON ROUGE LA
70809-3731
US

V. Phone/Fax

Practice location:
  • Phone: 225-763-4438
  • Fax: 225-763-4490
Mailing address:
  • Phone: 225-237-1754
  • Fax: 225-237-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0088212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: