Provider Demographics
NPI:1093710402
Name:FONTICOBA, ALBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:
Last Name:FONTICOBA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-4723
Mailing Address - Country:US
Mailing Address - Phone:215-463-5889
Mailing Address - Fax:215-755-6959
Practice Address - Street 1:330 W OREGON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-4723
Practice Address - Country:US
Practice Address - Phone:215-463-5889
Practice Address - Fax:215-755-6959
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
PAOEG000907152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1306195Medicaid
PA1306195Medicaid
PAT92050Medicare UPIN