Provider Demographics
NPI:1710026943
Name:FONTAINE, MARK S (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:FONTAINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:S
Other - Last Name:FONTAINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OPTOMETRIST
Mailing Address - Street 1:59 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-5507
Mailing Address - Country:US
Mailing Address - Phone:978-537-6324
Mailing Address - Fax:978-537-0804
Practice Address - Street 1:59 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-5507
Practice Address - Country:US
Practice Address - Phone:978-537-6324
Practice Address - Fax:978-537-0804
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3424152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist