Basic Information
Provider Information | |||||||||
NPI: | 1902801392 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FIDANZA | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | FRANCIS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | PSY.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 770 | ||||||||
Address2: |   | ||||||||
City: | ZACHARY | ||||||||
State: | LA | ||||||||
PostalCode: | 707910770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2253062000 | ||||||||
FaxNumber: | 2256581249 | ||||||||
Practice Location | |||||||||
Address1: | 6351 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ZACHARY | ||||||||
State: | LA | ||||||||
PostalCode: | 707914038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2253062000 | ||||||||
FaxNumber: | 2256581282 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2005 | ||||||||
LastUpdateDate: | 07/21/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP0016X | 1040MP | LA | Y |   | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
ID Information
ID | Type | State | Issuer | Description | 2125958 | 05 | LA |   | MEDICAID |