Provider Demographics
NPI:1366456964
Name:FOUNTAIN, GREGORY TODD (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:TODD
Last Name:FOUNTAIN
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 1:766 WALTHER ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046
Mailing Address - Country:US
Mailing Address - Phone:678-985-8001
Mailing Address - Fax:
Practice Address - Street 1:766 WALTHER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8764
Practice Address - Country:US
Practice Address - Phone:678-985-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034593207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA314606OtherWELLCARE
GA10045970OtherAMERIGROUP
GA00509594EMedicaid
GA10045970OtherAMERIGROUP
GA16BDTQNMedicare ID - Type Unspecified