Provider Demographics
NPI:1538373956
Name:FONTENOT, MARTY WILLIAM (DPT)
Entity type:Individual
Prefix:
First Name:MARTY
Middle Name:WILLIAM
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 ANGUS RD
Mailing Address - Street 2:STE 107
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-2768
Mailing Address - Country:US
Mailing Address - Phone:434-295-4473
Mailing Address - Fax:434-295-2691
Practice Address - Street 1:2114 ANGUS RD
Practice Address - Street 2:SUITE 107
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-2768
Practice Address - Country:US
Practice Address - Phone:434-295-4473
Practice Address - Fax:434-295-2691
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2011-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052072202251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09457Medicare PIN