Healthcare Provider Details

I. General information

NPI: 1659314623
Provider Name (Legal Business Name): JOHN L FAMBROUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15781 PROFESSIONAL PLZ
HAMMOND LA
70403-1452
US

IV. Provider business mailing address

15781 PROFESSIONAL PLZ
HAMMOND LA
70403-1452
US

V. Phone/Fax

Practice location:
  • Phone: 985-542-1533
  • Fax: 985-542-6713
Mailing address:
  • Phone: 985-542-1533
  • Fax: 985-542-6713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number011330
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: