Healthcare Provider Details

I. General information

NPI: 1134319320
Provider Name (Legal Business Name): FAJARDO MEDICAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
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 TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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