Provider Demographics
NPI:1245528520
Name:FONTAINE, ERIN (OD)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:719 GREEN VALLEY RD
Mailing Address - Street 2:STE 105
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7022
Mailing Address - Country:US
Mailing Address - Phone:336-230-1010
Mailing Address - Fax:336-230-1019
Practice Address - Street 1:1364 WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2932
Practice Address - Country:US
Practice Address - Phone:336-768-4140
Practice Address - Fax:336-768-4487
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC1653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC6962AMedicare UPIN