Provider Demographics
NPI:1386004083
Name:FONS VITAE INTL, INC
Entity Type:Organization
Organization Name:FONS VITAE INTL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADM
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-519-9200
Mailing Address - Street 1:1220 N ST NW APT 4A
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20005-5161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6144 OXON HILL RD
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3107
Practice Address - Country:US
Practice Address - Phone:202-215-0245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0078086207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty