Provider Demographics
NPI:1669405064
Name:FONTE, HIYAS DUNGO (MD)
Entity type:Individual
Prefix:
First Name:HIYAS
Middle Name:DUNGO
Last Name:FONTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HIYAS
Other - Middle Name:D
Other - Last Name:FONTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:731 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6377
Mailing Address - Country:US
Mailing Address - Phone:817-912-8800
Mailing Address - Fax:817-912-8810
Practice Address - Street 1:731 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6377
Practice Address - Country:US
Practice Address - Phone:817-912-8800
Practice Address - Fax:817-912-8810
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4946929-1205207R00000X
TXM6618207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187761501Medicaid
TX8J9411Medicare PIN
TX187761501Medicaid
H43659Medicare UPIN