Provider Demographics
NPI:1144384066
Name:FONTAINE, RUTH SUZANNE (MD, MA)
Entity Type:Individual
Prefix:DR
First Name:RUTH
Middle Name:SUZANNE
Last Name:FONTAINE
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Gender:F
Credentials:MD, MA
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Mailing Address - Street 1:3600 HARBOR BLVD
Mailing Address - Street 2:80
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93035-4136
Mailing Address - Country:US
Mailing Address - Phone:805-901-7644
Mailing Address - Fax:805-985-3711
Practice Address - Street 1:8879 LAUREL CANYON BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-2959
Practice Address - Country:US
Practice Address - Phone:818-252-2000
Practice Address - Fax:818-252-6896
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2011-01-24
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Provider Licenses
StateLicense IDTaxonomies
CAA 411992083P0500X, 208VP0000X
CAA41199208D00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29331Medicare UPIN