Provider Demographics
NPI:1922195635
Name:FONTANA, SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:FONTANA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18869 KABOT COVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6800
Mailing Address - Country:US
Mailing Address - Phone:952-200-7271
Mailing Address - Fax:
Practice Address - Street 1:18488 KENYON AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6911
Practice Address - Country:US
Practice Address - Phone:952-435-3505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2182152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410001863Medicare ID - Type Unspecified
MNT90872Medicare UPIN