Provider Demographics
NPI:1669688412
Name:FONTANILLA, JOHN R (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:FONTANILLA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4453 CASTOR AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3846
Mailing Address - Country:US
Mailing Address - Phone:215-744-2266
Mailing Address - Fax:215-743-9247
Practice Address - Street 1:4453 CASTOR AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3846
Practice Address - Country:US
Practice Address - Phone:215-744-2266
Practice Address - Fax:215-743-9247
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2012-07-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMT188798207R00000X
PAMD445193207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007278000113OtherTPI MEDICAID GROUP
PACD4829OtherTPI RAILROAD MEDICARE GROUP ID
PA597586OtherTPI MEDICARE GROUP