Provider Demographics
NPI:1013995901
Name:FOUNTAIN, TODD E (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:E
Last Name:FOUNTAIN
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 1:6325 HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2300
Mailing Address - Country:US
Mailing Address - Phone:901-522-7700
Mailing Address - Fax:
Practice Address - Street 1:6325 HUMPHREYS BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2300
Practice Address - Country:US
Practice Address - Phone:901-522-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45712207T00000X
MS20877207T00000X
TN44723207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN266914500Medicaid
I01486Medicare UPIN
MN140000276Medicare ID - Type Unspecified
MN140000396Medicare PIN