Basic Information
| Provider Information | |||||||||
| NPI: | 1568438984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FASTABEND | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373128247 | ||||||||
| FaxNumber: | 3374934355 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373128247 | ||||||||
| FaxNumber: | 3374934355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2006 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 04492R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1193887 | 05 | LA | MEDICAID |