Provider Demographics
NPI:1225042864
Name:FOUNTAIN, JOSEPH DONALD (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:DONALD
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5907 BERRYHILL RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-8278
Mailing Address - Country:US
Mailing Address - Phone:850-623-9787
Mailing Address - Fax:850-626-7512
Practice Address - Street 1:5907 BERRYHILL RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-8278
Practice Address - Country:US
Practice Address - Phone:850-623-9787
Practice Address - Fax:850-626-7512
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8585207Q00000X
FLOS13123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51546877OtherBCBS OF AL
AL51546878OtherBLUE CROSS BLUE SHIELD OF AL
FL267486600Medicaid
FL57900OtherFL BLUE
FL267486600Medicaid
FL57900Medicare ID - Type Unspecified
AL51546878OtherBLUE CROSS BLUE SHIELD OF AL