Provider Demographics
NPI:1164411096
Name:ABELLO, FORTUNATO BANZON (MD)
Entity Type:Individual
Prefix:DR
First Name:FORTUNATO
Middle Name:BANZON
Last Name:ABELLO
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 1:3015 SAN PEDRO AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2204
Mailing Address - Country:US
Mailing Address - Phone:210-737-2262
Mailing Address - Fax:210-737-3940
Practice Address - Street 1:3015 SAN PEDRO AVE
Practice Address - Street 2:STE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2204
Practice Address - Country:US
Practice Address - Phone:210-737-2262
Practice Address - Fax:210-737-3940
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6252225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
B20759Medicare UPIN
DE78Medicare ID - Type Unspecified