Provider Demographics
NPI:1750367074
Name:FONTANA-PENN, MARY E (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:FONTANA-PENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5430 CAMPBELL BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-5503
Mailing Address - Country:US
Mailing Address - Phone:410-933-9404
Mailing Address - Fax:
Practice Address - Street 1:7939 HONEYGO BLVD
Practice Address - Street 2:SUITE 219
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4931
Practice Address - Country:US
Practice Address - Phone:410-931-0404
Practice Address - Fax:410-931-0405
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0069408207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00107269Medicare PIN
G23102Medicare UPIN