Provider Demographics
NPI:1164962452
Name:PANTOJA, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:PANTOJA
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:D39 URB VILLA REAL
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-3980
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:D39 URB VILLA REAL
Practice Address - Street 2:
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-3980
Practice Address - Country:US
Practice Address - Phone:787-858-2818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1138106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist