Provider Demographics
NPI:1447543236
Name:BOHANON, FREDRICK JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:JAMES
Last Name:BOHANON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 MCHUGH RD STE C
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-5364
Mailing Address - Country:US
Mailing Address - Phone:225-570-2489
Mailing Address - Fax:
Practice Address - Street 1:4801 MCHUGH RD STE C
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-5364
Practice Address - Country:US
Practice Address - Phone:225-570-2489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0040982208600000X
TXQ1573208600000X
LA312263208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP1-0040982OtherTEXAS MEDICAL BOARD, POSTGRADUATE TRAINING PERMIT
LA2505696Medicaid
LA6B4259OtherFMC PTAN
LA14457559OtherCAQH