Provider Demographics
NPI:1508840570
Name:FONTANA, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
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 1:227 W JANSS RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1848
Mailing Address - Country:US
Mailing Address - Phone:805-852-9100
Mailing Address - Fax:805-852-9101
Practice Address - Street 1:215 W JANSS RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1847
Practice Address - Country:US
Practice Address - Phone:805-852-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263949208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF66021Medicare UPIN
NYA400063311Medicare PIN