Provider Demographics
NPI:1144280546
Name:FONTENOT, ANN BALLWEG (OD)
Entity type:Individual
Prefix:DR
First Name:ANN
Middle Name:BALLWEG
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:6520 JOSEPHINE DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-4979
Mailing Address - Country:US
Mailing Address - Phone:817-563-0022
Mailing Address - Fax:817-473-0013
Practice Address - Street 1:2925 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9184
Practice Address - Country:US
Practice Address - Phone:817-477-0223
Practice Address - Fax:817-277-9086
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06298TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU97661Medicare UPIN
TXAB3051Medicare ID - Type Unspecified