Provider Demographics
NPI:1124239710
Name:FONTAN, ANGEL L (MA)
Entity type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:L
Last Name:FONTAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MRS
Other - First Name:MARIA
Other - Middle Name:S
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSY D
Mailing Address - Street 1:E12 CALLE BENITEZ
Mailing Address - Street 2:SIERRA BERDECIA
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-6231
Mailing Address - Country:US
Mailing Address - Phone:787-789-1712
Mailing Address - Fax:
Practice Address - Street 1:1106 CALLE 41
Practice Address - Street 2:VILLA NEVAREZ
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00927-5102
Practice Address - Country:US
Practice Address - Phone:787-758-8019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8772084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry