Provider Demographics
NPI:1982629762
Name:FONTILLAS, RICARDO ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:ALLEN
Last Name:FONTILLAS
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 1:1090 WIGWAM PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-8181
Mailing Address - Country:US
Mailing Address - Phone:702-454-0201
Mailing Address - Fax:702-454-1245
Practice Address - Street 1:1090 WIGWAM PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-8181
Practice Address - Country:US
Practice Address - Phone:702-454-0201
Practice Address - Fax:702-454-1245
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV65012084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019612Medicaid
E52260Medicare UPIN
NVV36319Medicare PIN