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General NPI Number Information
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NPI Number | 1639378086
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Entity Type | Organization
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Legal Business Name | DIANE L. FOUNTAS M.D.
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Dates
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Enumeration Date | 07/16/2007
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Last Update Date | 07/16/2007
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Provider Practice Location Address
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Address Line | 1389 W MAIN ST SUITE 325
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City | WATERBURY
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State | CT
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Zip | 06708-3104
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Country | US
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Telephone | 203-753-6776
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Fax |
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Provider Business Mailing Address
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Address Line | 1389 W MAIN ST SUITE 325
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City | WATERBURY
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State | CT
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Zip | 06708-3104
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Country | US
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Telephone | 203-753-6776
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. TAMMY CARRASQUILLO
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Credential |
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Telephone | 203-753-6776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 024436
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License Number State | CT
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