Provider Demographics
NPI:1043228752
Name:FONTANA, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:FONTANA
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 1:106 CAPERS ST
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5202
Mailing Address - Country:US
Mailing Address - Phone:843-524-8151
Mailing Address - Fax:843-524-1954
Practice Address - Street 1:989 RIBAUT RD STE 210
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5481
Practice Address - Country:US
Practice Address - Phone:843-524-8151
Practice Address - Fax:843-524-1954
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC075723207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC075723/PA0726Medicaid
SC075723/PA0726Medicaid
SCNSC0836980001Medicare ID - Type Unspecified