Basic Information
| Provider Information | |||||||||
| NPI: | 1124091574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANTAGNAN | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4228 HOUMA BLVD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700063000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048895250 | ||||||||
| FaxNumber: | 5048895288 | ||||||||
| Practice Location | |||||||||
| Address1: | 4228 HOUMA BLVD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700063000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048895250 | ||||||||
| FaxNumber: | 5048895288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 024747 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1575208 | 05 | LA | MEDICAID | 4E268DH01 | 01 | LA | MEDICARE PTAN | OTHER |