Provider Demographics
NPI:1225041965
Name:FONTANAZZA, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FONTANAZZA
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 1:450 BERGEN ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07029
Mailing Address - Country:US
Mailing Address - Phone:973-484-6900
Mailing Address - Fax:973-484-0029
Practice Address - Street 1:450 BERGEN ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NJ
Practice Address - Zip Code:07029
Practice Address - Country:US
Practice Address - Phone:973-484-6900
Practice Address - Fax:973-484-0029
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ32061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD02037000OtherCDS
NJAF7428003OtherDEA
C53605Medicare UPIN
153763BPXMedicare ID - Type Unspecified