Healthcare Provider Details

I. General information

NPI: 1972504355
Provider Name (Legal Business Name): EMILY FONTANE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH STREET
JACKSONVILLE FL
32209
US

IV. Provider business mailing address

PO BOX 44008 UFJP PROVIDER ENROLLMENT
JACKSONVILLE FL
32231
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-5044
  • Fax: 904-244-4508
Mailing address:
  • Phone: 904-244-3660
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberD67938
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberD67938
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME99702
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: