Provider Demographics
NPI:1497712640
Name:FONTANILLA, JOSE ALBERT ANG JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ALBERT ANG
Last Name:FONTANILLA
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:2422 N THOMPSON SUITE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764
Mailing Address - Country:US
Mailing Address - Phone:479-750-6566
Mailing Address - Fax:479-750-5251
Practice Address - Street 1:4077 ELM SPRINGS RD STE 105
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-3703
Practice Address - Country:US
Practice Address - Phone:479-927-2100
Practice Address - Fax:479-927-2211
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2020-09-09
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Provider Licenses
StateLicense IDTaxonomies
ARE3107207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146213001Medicaid
ARG39834Medicare UPIN
AR146213001Medicaid