Provider Demographics
NPI:1689756918
Name:FONTANIER, CHARLES EUGENE (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EUGENE
Last Name:FONTANIER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W GREENS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77067-4605
Mailing Address - Country:US
Mailing Address - Phone:281-872-7676
Mailing Address - Fax:281-872-0569
Practice Address - Street 1:210 W GREENS RD
Practice Address - Street 2:SUITE C
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77067
Practice Address - Country:US
Practice Address - Phone:281-872-7676
Practice Address - Fax:281-872-0569
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3960208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115903001Medicaid
00RW47Medicare ID - Type Unspecified
A66420Medicare UPIN