Provider Demographics
NPI:1073780649
Name:FONTAIN ORTIZ, ZORAIDA
Entity Type:Individual
Prefix:
First Name:ZORAIDA
Middle Name:
Last Name:FONTAIN ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 CALLE EIDER
Mailing Address - Street 2:COUNTRY CLUB
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924-2335
Mailing Address - Country:US
Mailing Address - Phone:787-757-1305
Mailing Address - Fax:
Practice Address - Street 1:969 CALLE EIDER
Practice Address - Street 2:COUNTRY CLUB
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-2335
Practice Address - Country:US
Practice Address - Phone:787-757-1305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3018246QM0706X
246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR30931Medicare PIN