Provider Demographics
NPI:1336108737
Name:FONTANA, MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FONTANA
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 1:235 AARAMAR LN
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8205
Mailing Address - Country:US
Mailing Address - Phone:505-803-5554
Mailing Address - Fax:
Practice Address - Street 1:235 AARAMAR LN
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8205
Practice Address - Country:US
Practice Address - Phone:505-803-5554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20020278173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH15559Medicare UPIN