MEDICARE: DR. RUTH SUZANNE FONTAINE M.D., M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083P0500X	Preventive Medicine/Occupational Environmental Medicine Physician	A 41199	CA
2	208VP0000X	Pain Medicine Physician	A 41199	CA
3	208D00000X	General Practice Physician	A41199	CA
4	2083P0901X	Public Health & General Preventive Medicine Physician	A41199	CA

General Provider Information

NPI Number	:	1144384066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUTH SUZANNE FONTAINE M.D., M.A.

Provider Business Mailing Address
First Line	:	3600 HARBOR BLVD
Second Line	:	80
City	:	OXNARD
State	:	CA
Zip	:	93035-4136
Country	:	US
Telephone Number	:	805-901-7644
Fax Number	:	805-985-3711

Provider Business Practice Location Address
First Line	:	8879 LAUREL CANYON BLVD
Second Line	:	SUITE C
City	:	SUN VALLEY
State	:	CA
Zip	:	91352-2959
Country	:	US
Telephone Number	:	818-252-2000
Fax Number	:	818-252-6896

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	01/24/2011

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