Individual
DR. LARRY L FONTANILLA JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
413 LILLY RD NE, OLYMPIA, WA 98506-5133
(360) 491-9480
Mailing address
PO BOX 5007, LACEY, WA 98509-5007
(800) 599-0166
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
MD00043682
WA
207R00000X
Internal Medicine Physician
MD00043682
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
191058
WA L & I
—
01
—
2537FO
REGENCE BS
—
05
—
8396830
—
WA
01
—
8939281
WA CRIME VICTIMS
—
01
—
H39247
GROUP HEALTH
—
01
—
P00234764
RAILROAD MEDICARE
—
Enumeration date
06/09/2006
Last updated
11/27/2007
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