Provider Demographics
NPI:1528180569
Name:FONTEJON, EDWIN ADAJAR (OTR)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:ADAJAR
Last Name:FONTEJON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:MR
Other - First Name:EDWIN
Other - Middle Name:A
Other - Last Name:FONTEJON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:2375 MARTINEZ CT
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-1160
Mailing Address - Country:US
Mailing Address - Phone:510-672-4414
Mailing Address - Fax:
Practice Address - Street 1:800 SERENO DR RM 288
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2411
Practice Address - Country:US
Practice Address - Phone:707-651-4173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 2548225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist