Provider Demographics
NPI:1972504355
Name:FONTANE, EMILY (MD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:
Last Name:FONTANE
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231
Mailing Address - Country:US
Mailing Address - Phone:904-244-3660
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:655 W 8TH STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209
Practice Address - Country:US
Practice Address - Phone:904-244-5044
Practice Address - Fax:904-244-4508
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD679382080P0203X, 2080P0204X
FLME99702207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279794101Medicaid
MD415631500Medicaid
GA003105963AMedicaid
NC89129EXMedicaid
NC930109142OtherRAILROAD MEDICARE
NC129EXOtherBCBS NC
MD134411ZAKHMedicare PIN
NC930109142OtherRAILROAD MEDICARE
NC129EXOtherBCBS NC
NC89129EXMedicaid