Provider Demographics
NPI:1629000724
Name:FONTAINE, LUC OCTAVE (MD)
Entity Type:Individual
Prefix:
First Name:LUC
Middle Name:OCTAVE
Last Name:FONTAINE
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 1:233 W COLE BLVD
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-9722
Mailing Address - Country:US
Mailing Address - Phone:760-357-2020
Mailing Address - Fax:760-357-1056
Practice Address - Street 1:233 W COLE BLVD
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-9722
Practice Address - Country:US
Practice Address - Phone:760-357-2020
Practice Address - Fax:760-357-1056
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36515207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology