Provider Demographics
NPI:1063807774
Name:FONTEM, RODRIGUE (MD)
Entity type:Individual
Prefix:DR
First Name:RODRIGUE
Middle Name:
Last Name:FONTEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E SPRUCE ST STE 3B
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-5685
Mailing Address - Country:US
Mailing Address - Phone:620-275-3740
Mailing Address - Fax:620-275-3761
Practice Address - Street 1:701 N 1ST ST STE D327
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3757
Practice Address - Country:US
Practice Address - Phone:217-545-8856
Practice Address - Fax:217-545-7762
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT211330208600000X
IL125.077903208C00000X
390200000X
KS04-46768208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program