Provider Demographics
NPI:1912023763
Name:FAJARDO MEDICAL PRACTICE
Entity Type:Organization
Organization Name:FAJARDO MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AGAPITO
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTANEZ NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-863-7646
Mailing Address - Street 1:PO BOX 827
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-0827
Mailing Address - Country:US
Mailing Address - Phone:787-863-7646
Mailing Address - Fax:787-860-7357
Practice Address - Street 1:I23 CALLE PRINCIPAL
Practice Address - Street 2:URB. BARALT
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-3772
Practice Address - Country:US
Practice Address - Phone:787-863-7646
Practice Address - Fax:787-860-7357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR207R00000X, 208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty