Provider Demographics
NPI:1700822574
Name:MATTA FONTANET, EVELYN (MD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:
Last Name:MATTA FONTANET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 CALLE GARDENIA
Mailing Address - Street 2:LA PONDEROSA
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-2201
Mailing Address - Country:US
Mailing Address - Phone:787-809-4025
Mailing Address - Fax:787-809-4025
Practice Address - Street 1:21 LAS FLORES
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-809-4025
Practice Address - Fax:787-809-4025
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13484207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR13484OtherMEDICAL LICENSE