Provider Demographics
NPI:1023000429
Name:FONTAINE, DARRYL (MD)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:
Last Name:FONTAINE
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 1:1 FONTAINE CT
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-392-4981
Mailing Address - Fax:423-245-5032
Practice Address - Street 1:4105 FORT HENRY DRIVE
Practice Address - Street 2:SUITE 207
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663
Practice Address - Country:US
Practice Address - Phone:423-239-5833
Practice Address - Fax:423-239-9789
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20124207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0221312000Medicaid
NC890576LMedicaid
TN0100OtherJOHN DEERE
3046989OtherBLUE SHIELD OF TN
TN3051034Medicaid
00013859OtherNHC CARE ADMINISTRATORS
100011235OtherPHP TENNCARE
VA5747040Medicaid
KY64911142Medicaid
063263OtherANTHEM BCBS
E56409Medicare UPIN
00013859OtherNHC CARE ADMINISTRATORS
100011235OtherPHP TENNCARE