Individual
GREGORY TODD FOUNTAIN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
766 WALTHER RD, SUITE 100, LAWRENCEVILLE, GA 30046-8764
(678) 985-8001
Mailing address
766 WALTHER ROAD, SUITE 100, LAWRENCEVILLE, GA 30046
(678) 985-8001
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
034593
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00509594E
—
GA
01
—
10045970
AMERIGROUP
GA
01
—
314606
WELLCARE
GA
Enumeration date
07/28/2006
Last updated
08/17/2022
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