Individual
KELLY FOUNTAIN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1223 GATEWAY DR, MELBOURNE, FL 32901-2607
(321) 728-6002
Mailing address
4020 TURKEY POINT DR, MELBOURNE, FL 32934-8584
(251) 363-1745
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
04-37158
KS
2085R0202X
Diagnostic Radiology Physician
23930
MS
2085R0202X
Diagnostic Radiology Physician
30719
AL
2085R0202X
Diagnostic Radiology Physician
DR.0057830
CO
2085R0202X
Diagnostic Radiology Physician
Primary
ME 129581
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
MA915
MEDICARE
FL
05
—
PENDING
—
FL
Enumeration date
07/16/2009
Last updated
05/10/2020
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