Provider Demographics
NPI:1790786937
Name:FONTENOT, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:FONTENOT
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 1:1331 BANDERA HWY STE 10
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-9535
Mailing Address - Country:US
Mailing Address - Phone:830-257-1440
Mailing Address - Fax:830-257-2542
Practice Address - Street 1:1331 BANDERA HWY STE 10
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-9535
Practice Address - Country:US
Practice Address - Phone:830-257-1440
Practice Address - Fax:830-257-2542
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5761208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX106116OtherSUPERIOR CHIP
TX130580703Medicaid
TX0085EYOtherBCBS
TX130580703Medicaid