Provider Demographics
NPI:1003292475
Name:FAJARDO PEDIATRIC CENTER
Entity Type:Organization
Organization Name:FAJARDO PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AGAPITO
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTANEZ NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-368-8282
Mailing Address - Street 1:13 CASTILLOS DEL MAR
Mailing Address - Street 2:
Mailing Address - City:CEIBA
Mailing Address - State:PR
Mailing Address - Zip Code:00735-3616
Mailing Address - Country:US
Mailing Address - Phone:787-368-8282
Mailing Address - Fax:787-655-7693
Practice Address - Street 1:13 CASTILLOS DEL MAR
Practice Address - Street 2:
Practice Address - City:CEIBA
Practice Address - State:PR
Practice Address - Zip Code:00735-3616
Practice Address - Country:US
Practice Address - Phone:787-368-8282
Practice Address - Fax:787-655-7693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4710261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care