Healthcare Provider Details

I. General information

NPI: 1538153648
Provider Name (Legal Business Name): EILEEN MARY KATHRYN FONTANETTA M.D. F.A.A.P.,M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 BROWN ST
SEA CLIFF NY
11579-1602
US

IV. Provider business mailing address

188 BROWN ST
SEA CLIFF NY
11579-1602
US

V. Phone/Fax

Practice location:
  • Phone: 516-674-0959
  • Fax: 718-380-3214
Mailing address:
  • Phone: 516-674-0959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number164801
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: