Provider Demographics
NPI:1700016359
Name:FOUNTAIN, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 TURKEY POINT DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-8584
Mailing Address - Country:US
Mailing Address - Phone:251-363-1745
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-728-6002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS239302085R0202X
AL307192085R0202X
CODR.00578302085R0202X
KS04-371582085R0202X
FLME 1295812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FLMA915OtherMEDICARE