Healthcare Provider Details

I. General information

NPI: 1649654062
Provider Name (Legal Business Name): FONTANA CARDIOVASCULAR GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8635 WEST THRID STREET SUITE 750W
LOS ANGELES CA
90048
US

IV. Provider business mailing address

9663 SANTA MONICA BLVD NO 756
BEVERLY HILLS CA
90210-4303
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-2030
  • Fax:
Mailing address:
  • Phone: 310-721-2285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG P FONTANA
Title or Position: PRESIDENT
Credential: MD
Phone: 310-721-2285