Healthcare Provider Details

I. General information

NPI: 1013995901
Provider Name (Legal Business Name): TODD E FOUNTAIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 RUE LOUIS XIV
LAFAYETTE LA
70508-5739
US

IV. Provider business mailing address

108 RUE LOUIS XIV
LAFAYETTE LA
70508-5739
US

V. Phone/Fax

Practice location:
  • Phone: 337-235-8007
  • Fax: 337-235-8008
Mailing address:
  • Phone: 337-235-8007
  • Fax: 337-235-8008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number343016
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: