Provider Demographics
NPI:1134319320
Name:FAJARDO MEDICAL PRACTICE
Entity type:Organization
Organization Name:FAJARDO MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
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:MD
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?:Yes
Parent Organization LBN:FAJARDO MEDICAL PRACTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty