Provider Demographics
NPI:1679538904
Name:FRONTERA, JUAN RENE (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:RENE
Last Name:FRONTERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:RENE
Other - Last Name:FRONTERA-CASTILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:20952 E 12 MILE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3200
Practice Address - Country:US
Practice Address - Phone:586-771-4820
Practice Address - Fax:586-771-6620
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053764208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF10966OtherHAP
MI132311OtherPRIORITY HEALTH
MI5733698OtherAETNA
MI3235841007OtherCIGNA
MI340019038OtherRAILROAD MEDICARE
MI0219690001Medicare NSC
MI132311OtherPRIORITY HEALTH
MI0E06273023Medicare PIN