Individual
DR. JOHN R FONTANILLA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4453 CASTOR AVE, SUITE B, PHILADELPHIA, PA 19124-3846
(215) 744-2266
(215) 743-9247
Mailing address
4453 CASTOR AVE, SUITE B, PHILADELPHIA, PA 19124-3846
(215) 744-2266
(215) 743-9247
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
MT188798
PA
207RN0300X
Nephrology Physician
Primary
MD445193
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1007278000113
TPI MEDICAID GROUP
PA
01
—
597586
TPI MEDICARE GROUP
PA
01
—
CD4829
TPI RAILROAD MEDICARE GROUP ID
PA
Enumeration date
05/15/2007
Last updated
07/27/2012
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