Provider Demographics
NPI:1841408879
Name:FONTALVO-HERAZO, LUCIA FERNANDA (MD)
Entity Type:Individual
Prefix:
First Name:LUCIA
Middle Name:FERNANDA
Last Name:FONTALVO-HERAZO
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 1:1900 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-2304
Mailing Address - Country:US
Mailing Address - Phone:215-590-2575
Mailing Address - Fax:215-590-5797
Practice Address - Street 1:34TH STREET AND CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-6503
Practice Address - Country:US
Practice Address - Phone:215-590-2575
Practice Address - Fax:215-590-5797
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PALT0006222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENDINGMedicaid
PAPENDINGMedicaid