Healthcare Provider Details

I. General information

NPI: 1912023763
Provider Name (Legal Business Name): FAJARDO MEDICAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I23 CALLE PRINCIPAL URB. BARALT
FAJARDO PR
00738-3772
US

IV. Provider business mailing address

PO BOX 827
FAJARDO PR
00738-0827
US

V. Phone/Fax

Practice location:
  • Phone: 787-863-7646
  • Fax: 787-860-7357
Mailing address:
  • Phone: 787-863-7646
  • Fax: 787-860-7357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StatePR

VIII. Authorized Official

Name: DR. AGAPITO FONTANEZ NIEVES
Title or Position: PRESIDENT
Credential:
Phone: 787-863-7646