Provider Demographics
NPI:1407275530
Name:FONTAINE, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 MIDDLEFORD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-3670
Mailing Address - Country:US
Mailing Address - Phone:302-629-5700
Mailing Address - Fax:302-629-6001
Practice Address - Street 1:1310 MIDDLEFORD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3670
Practice Address - Country:US
Practice Address - Phone:302-629-5700
Practice Address - Fax:302-629-6001
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEK7520021OtherCAREFIRST
DEP01401462OtherRR MEDICARE
DE1407275530Medicaid
DE346204YBWEOtherMEDICARE