Provider Demographics
NPI:1851395826
Name:FONTANEZ, MODESTO (MD)
Entity Type:Individual
Prefix:DR
First Name:MODESTO
Middle Name:
Last Name:FONTANEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 8
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7647
Mailing Address - Country:US
Mailing Address - Phone:631-738-8300
Mailing Address - Fax:631-738-8500
Practice Address - Street 1:2805 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE 8
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7647
Practice Address - Country:US
Practice Address - Phone:631-738-8300
Practice Address - Fax:631-738-8500
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083857207T00000X
NY181810-4207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2463258Medicaid
OH2463258Medicaid