Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 016613 | LA |
NPI | 1225034812 |
---|---|
Provider Name | Mr. Bernard C Fruge JR. |
First Address | Lafayette, LA 70508 |
Second Address | Lafayette, LA 70508 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2005 |
Last Update Date | 02/12/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1349691 | (05) | LA |
D29505 | (02) | LA |