1720191778 NPI number — DR. ARNOLD GLEN FONTANILLA D.O.

Table of content: DR. ARNOLD GLEN FONTANILLA D.O. (NPI 1720191778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720191778 NPI number — DR. ARNOLD GLEN FONTANILLA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTANILLA
Provider First Name:
ARNOLD
Provider Middle Name:
GLEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720191778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 LIPPINCOTT DR STE 410
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARLTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08053-4197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-355-0340
Provider Business Mailing Address Fax Number:
856-355-0330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6981 NORTH PARK DRIVE
Provider Second Line Business Practice Location Address:
COOOPER RIVER WEST OFFICE BUILDING
Provider Business Practice Location Address City Name:
PENNSAUKEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-663-4949
Provider Business Practice Location Address Fax Number:
856-663-6076
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25MB07716400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: OS012536 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1014376180001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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