Provider Demographics
NPI:1902801392
Name:FIDANZA, JOHN FRANCIS III (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FRANCIS
Last Name:FIDANZA
Suffix:III
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 770
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-0770
Mailing Address - Country:US
Mailing Address - Phone:225-306-2000
Mailing Address - Fax:225-658-1249
Practice Address - Street 1:6351 MAIN ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4038
Practice Address - Country:US
Practice Address - Phone:225-306-2000
Practice Address - Fax:225-658-1282
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1040MP103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2125958Medicaid
LA2125958Medicaid