Provider Demographics
NPI:1952506362
Name:FONTANELLA LARA, ANTONIO RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:RAFAEL
Last Name:FONTANELLA LARA
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 1:37 FOX CHASE DR
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-9339
Mailing Address - Country:US
Mailing Address - Phone:786-417-1647
Mailing Address - Fax:
Practice Address - Street 1:37 FOX CHASE DR
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-9339
Practice Address - Country:US
Practice Address - Phone:786-417-1647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-16
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16362207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine