Provider Demographics
NPI:1104818954
Name:FONTANET GRANA, RICARDO M (MD)
Entity type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:M
Last Name:FONTANET GRANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:GO7 AVE CAMPO RICO
Mailing Address - Street 2:COUNTRY CLUB
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00982-2678
Mailing Address - Country:US
Mailing Address - Phone:787-633-8152
Mailing Address - Fax:787-762-9110
Practice Address - Street 1:GO7 AVE CAMPO RICO
Practice Address - Street 2:COUNTRY CLUB
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00982-2678
Practice Address - Country:US
Practice Address - Phone:787-633-8152
Practice Address - Fax:787-762-9110
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9201208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR061680OtherCRUZ AZUL
PR81706OtherSSS INSURANCE
PRP-1319OtherPALIC
PR129660590181OtherGLOBAL
PR9820006OtherHUMANA