Provider Demographics
NPI:1659464964
Name:FONTEYNE, DOUGLAS R (DC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:FONTEYNE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:DOUGLAS
Other - Middle Name:R
Other - Last Name:FONTEYNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:3756 S AMHERST HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572-5985
Mailing Address - Country:US
Mailing Address - Phone:434-929-4999
Mailing Address - Fax:434-929-4997
Practice Address - Street 1:3756 S. AMHERST HWY
Practice Address - Street 2:100
Practice Address - City:MADISON HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:24572-5985
Practice Address - Country:US
Practice Address - Phone:434-929-4999
Practice Address - Fax:434-929-4997
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001637111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA263552OtherANTHEM
VA2995862OtherCIGNA
VA350040203OtherRAILROAD MEDICARE
VA350000686Medicare PIN