Provider Demographics
NPI:1922088269
Name:FONTICIELLA, ADALBERTO R (MD)
Entity Type:Individual
Prefix:DR
First Name:ADALBERTO
Middle Name:R
Last Name:FONTICIELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W KINGSHIGHWAY
Mailing Address - Street 2:SUITE 12
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4141
Mailing Address - Country:US
Mailing Address - Phone:870-236-6930
Mailing Address - Fax:870-239-8065
Practice Address - Street 1:1000 WEST KINGSHIGHWAY
Practice Address - Street 2:SUITE 12
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-8894
Practice Address - Country:US
Practice Address - Phone:870-236-6930
Practice Address - Fax:870-239-8065
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-6766208600000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157456002Medicaid
AR5F322Medicare PIN
C68296Medicare UPIN