Healthcare Provider Details

I. General information

NPI: 1629076906
Provider Name (Legal Business Name): JOHN A. FOUNTAIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1349 MILSTEAD RD NE
CONYERS GA
30012-3871
US

IV. Provider business mailing address

2400 BELLEVUE RD SUITE 21-A
DUBLIN GA
31021-2885
US

V. Phone/Fax

Practice location:
  • Phone: 770-922-1716
  • Fax: 770-760-9504
Mailing address:
  • Phone: 478-275-7202
  • Fax: 478-274-8418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number021688
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number021688
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number021688
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number021688
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number021688
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number021688
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: