Provider Demographics
NPI:1336696541
Name:FONTANA, EDUARDO
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:FONTANA
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 1:9929 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6175
Mailing Address - Country:US
Mailing Address - Phone:954-437-8099
Mailing Address - Fax:
Practice Address - Street 1:9929 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6175
Practice Address - Country:US
Practice Address - Phone:954-437-8099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27035225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant