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General NPI Number Information
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NPI Number | 1538373956
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Entity Type | Individual
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Provider Name | MARTY WILLIAM FONTENOT DPT
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Gender | Male
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 12/04/2011
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Provider Practice Location Address
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Address Line | 2114 ANGUS RD SUITE 107
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-2768
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Country | US
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Telephone | 434-295-4473
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Fax | 434-295-2691
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Provider Business Mailing Address
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Address Line | 2114 ANGUS RD STE 107
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-2768
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Country | US
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Telephone | 434-295-4473
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Fax | 434-295-2691
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 2305207220
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License Number State | VA
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