Provider Demographics
NPI:1518965292
Name:FONTANA, KELLY A (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:FONTANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1585 PINE RIDGE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-2105
Mailing Address - Country:US
Mailing Address - Phone:239-451-3143
Mailing Address - Fax:239-451-3145
Practice Address - Street 1:1585 PINE RIDGE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-2105
Practice Address - Country:US
Practice Address - Phone:239-451-3143
Practice Address - Fax:239-451-3145
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98117207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4603282Medicaid
FL277788600Medicaid
FLAD185YOtherMEDICARE PTAN
MIM74040005Medicare ID - Type Unspecified
MI4603282Medicaid