Provider Demographics
NPI:1063792349
Name:FONTANEZ, KARLA MICHELLE (MD)
Entity type:Individual
Prefix:MISS
First Name:KARLA
Middle Name:MICHELLE
Last Name:FONTANEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VERDE LUZ ST. / URB. PRECIOSA
Mailing Address - Street 2:#4
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778-5163
Mailing Address - Country:US
Mailing Address - Phone:787-438-6690
Mailing Address - Fax:
Practice Address - Street 1:VERDE LUZ ST. / URB. PRECIOSA
Practice Address - Street 2:#4
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778-5163
Practice Address - Country:US
Practice Address - Phone:787-438-6690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18302208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR18302Medicaid
PR18302Medicare UPIN
PR18302Medicare PIN