Provider Demographics
NPI:1396324380
Name:FONTENOT, ROBERT RYAN (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:RYAN
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9812 SIERRA MORENA ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-1419
Mailing Address - Country:US
Mailing Address - Phone:713-572-5128
Mailing Address - Fax:
Practice Address - Street 1:160 S CAMINO DEL PUEBLO
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-6173
Practice Address - Country:US
Practice Address - Phone:505-771-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOPT733152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program