Provider Demographics
NPI:1255403010
Name:FONTANEZ, CARLOS AGAPITO (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:AGAPITO
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:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:PUERTO REAL
Mailing Address - State:PR
Mailing Address - Zip Code:00740-0458
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:AVE OSVALDO MOLINA #151
Practice Address - Street 2:SUITE 103
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-3614
Practice Address - Country:US
Practice Address - Phone:787-801-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16110207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0023494Medicare ID - Type Unspecified
PRI 43618Medicare UPIN