Active NPI
Fontaine Willis
- Driver
- San Bernardino, CA
National Provider Identifier
1184215550
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Driver
- License
- Y7940726
- Practice address
- 4420 N Varsity Ave Apt 1040
San Bernardino, CA 92407-4636 - Phone
- (213) 949-6845
- NPI assigned
- Jan 28, 2021
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Driver | 172A00000X | Y7940726 | CA | Primary |
Addresses
Primary practice location
4420 N Varsity Ave Apt 1040
San Bernardino, CA 92407-4636
Mailing address
4420 N Varsity Ave Apt 1040
San Bernardino, CA 92407-4636
Phone (213) 949-6845
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| Y7940726 | CA | MD | Driver |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1611792000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1611792000000",
"number": "1184215550",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4420 N VARSITY AVE APT 1040",
"city": "SAN BERNARDINO",
"state": "CA",
"postal_code": "924074636",
"telephone_number": "213-949-6845"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4420 N VARSITY AVE APT 1040",
"city": "SAN BERNARDINO",
"state": "CA",
"postal_code": "924074636",
"telephone_number": "213-949-6845"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILLIS",
"first_name": "FONTAINE",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2021-01-28",
"last_updated": "2021-01-28",
"certification_date": "2021-01-28",
"status": "A"
},
"taxonomies": [
{
"code": "172A00000X",
"taxonomy_group": "",
"desc": "Driver",
"state": "CA",
"license": "Y7940726",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Bernardino, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.