Healthcare Provider Details

I. General information

NPI: 1811545015
Provider Name (Legal Business Name): SANTOS EMMANUEL SANTOS FONTANEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

HC 2 BOX 48152
VEGA BAJA PR
00693-9678
US

V. Phone/Fax

Practice location:
  • Phone: 787-981-7040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberLP05438
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: