Provider Demographics
NPI:1265828107
Name:FONTAINE, CAMILLE (MD)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:187-920-4316
Mailing Address - Fax:718-881-2245
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:187-920-4316
Practice Address - Fax:718-881-2245
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305487207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty