Provider Demographics
NPI:1487305801
Name:FONTENOT, JD
Entity type:Individual
Prefix:
First Name:JD
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 BIRDSONG DR
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2543
Mailing Address - Country:US
Mailing Address - Phone:409-996-5616
Mailing Address - Fax:
Practice Address - Street 1:701 W PARKWOOD AVE
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-5405
Practice Address - Country:US
Practice Address - Phone:281-996-9971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41307183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician