Healthcare Provider Details

I. General information

NPI: 1265828107
Provider Name (Legal Business Name): CAMILLE FONTAINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

111 E 210TH ST
BRONX NY
10467-2401
US

V. Phone/Fax

Practice location:
  • Phone: 187-920-4316
  • Fax: 718-881-2245
Mailing address:
  • Phone: 187-920-4316
  • Fax: 718-881-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number305487
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number305487
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: