Basic Information
Provider Information | |||||||||
NPI: | 1346205184 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FONTAINE | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 703 RIVERWAY PL | ||||||||
Address2: |   | ||||||||
City: | BEDFORD | ||||||||
State: | NH | ||||||||
PostalCode: | 031106768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036687096 | ||||||||
FaxNumber: | 6036696944 | ||||||||
Practice Location | |||||||||
Address1: | 703 RIVERWAY PL | ||||||||
Address2: |   | ||||||||
City: | BEDFORD | ||||||||
State: | NH | ||||||||
PostalCode: | 031106768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036687096 | ||||||||
FaxNumber: | 6036696944 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2006 | ||||||||
LastUpdateDate: | 09/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 11108 | NH | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 01Y002791NH02 | 01 | NH | BLUE CROSS | OTHER | 01Y002791 NH05 | 01 | NH | ANTHEM MCH TAX ID | OTHER | 2486283 | 01 | NH | AETNA | OTHER | 294664 | 01 | NH | CIGNA | OTHER | 300113664 | 01 | NH | RAILROAD MEDICARE | OTHER | 101250 | 01 | NH | TUFTS | OTHER | 30201186 | 05 | NH |   | MEDICAID |