Healthcare Provider Details

I. General information

NPI: 1538802897
Provider Name (Legal Business Name): TYLER AUSTIN FONTAINE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9330 SR-54
TRINITY FL
34655
US

IV. Provider business mailing address

9330 FL-54 MEDICAL ARTS BUILDING SUITE 404
TRINITY FL
34655
US

V. Phone/Fax

Practice location:
  • Phone: 727-834-4830
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS22480
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: