Provider Demographics
NPI:1740308675
Name:FONTAN LASANTA, LUIS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:FONTAN LASANTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LUIS MUNOZ MARIN AVENUE
Mailing Address - Street 2:PMB 611 URB VILLA BLANCA
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-644-1333
Mailing Address - Fax:
Practice Address - Street 1:ROAD 14 KM 72.0 BO RINCON SEC LOMAS
Practice Address - Street 2:CENTRO MEDICO MENONITA CAYEY
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00737-2800
Practice Address - Country:US
Practice Address - Phone:877-535-1001
Practice Address - Fax:787-535-1012
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13566207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH64082Medicare UPIN