Provider Demographics
NPI:1063452522
Name:FONTANA, JOSEPH ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ALBERT
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 1:1560 E MAPLE ROAD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:800-527-6266
Mailing Address - Fax:313-576-8767
Practice Address - Street 1:4100 JOHN R HWCRC 4TH FL
Practice Address - Street 2:KARMANOS CANCER CENTER
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:800-527-6266
Practice Address - Fax:313-576-8767
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072612207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630226Medicare PIN