Provider Demographics
NPI:1386873388
Name:FOUNTAIN, HERMAN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:HERMAN
Middle Name:MICHAEL
Last Name:FOUNTAIN
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 1:362 17TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5690
Mailing Address - Country:US
Mailing Address - Phone:772-571-7016
Mailing Address - Fax:
Practice Address - Street 1:917 ORCHID POINT WAY
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963
Practice Address - Country:US
Practice Address - Phone:772-571-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-11
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine