Provider Demographics
NPI:1164436382
Name:FONTELERA, MICHAEL PONCO
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PONCO
Last Name:FONTELERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2111
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-2111
Mailing Address - Country:US
Mailing Address - Phone:925-249-1400
Mailing Address - Fax:925-249-1414
Practice Address - Street 1:4049 FIRST ST
Practice Address - Street 2:SUITE 134
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-5379
Practice Address - Country:US
Practice Address - Phone:925-249-1400
Practice Address - Fax:925-249-1414
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44039332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4597620003Medicare ID - Type Unspecified