Healthcare Provider Details

I. General information

NPI: 1700822574
Provider Name (Legal Business Name): EVELYN MATTA FONTANET M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 LAS FLORES
RIO GRANDE PR
00745
US

IV. Provider business mailing address

390 CALLE GARDENIA LA PONDEROSA
RIO GRANDE PR
00745-2201
US

V. Phone/Fax

Practice location:
  • Phone: 787-809-4025
  • Fax: 787-809-4025
Mailing address:
  • Phone: 787-809-4025
  • Fax: 787-809-4025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13484
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: