Provider Demographics
NPI:1033110978
Name:FOUNTAIN, TAMARA R (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:R
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:740 WAUKEGAN RD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4374
Mailing Address - Country:US
Mailing Address - Phone:847-945-6770
Mailing Address - Fax:847-945-3159
Practice Address - Street 1:740 WAUKEGAN RD
Practice Address - Street 2:SUITE 360
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4374
Practice Address - Country:US
Practice Address - Phone:847-945-6770
Practice Address - Fax:847-945-3159
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085597207W00000X
IL036085597207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085597Medicaid
180042658OtherRAILROAD MEDICARE
L82277Medicare PIN
ILG02720Medicare UPIN