Healthcare Provider Details

I. General information

NPI: 1194722637
Provider Name (Legal Business Name): LEO J FONTANA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SAINT GEORGES AVE
AVENEL NJ
07001-1000
US

IV. Provider business mailing address

1500 SAINT GEORGES AVE
AVENEL NJ
07001-1000
US

V. Phone/Fax

Practice location:
  • Phone: 732-381-8686
  • Fax: 732-499-7724
Mailing address:
  • Phone: 732-381-8686
  • Fax: 732-499-7724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA05939000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: