Provider Demographics
NPI:1336153576
Name:FONTANA, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:FONTANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:700 ACKERMAN RD
Mailing Address - Street 2:SUITE 385
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-947-3700
Mailing Address - Fax:614-947-3771
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-4967
Practice Address - Fax:614-293-5614
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35.029227207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0163004Medicaid
OHA732527Medicare UPIN
OH0163004Medicaid