Provider Demographics
NPI:1124783881
Name:PANTOJA, FIDEL ALEXANDER (OPTICIAN)
Entity type:Individual
Prefix:
First Name:FIDEL
Middle Name:ALEXANDER
Last Name:PANTOJA
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 W WINNIPEG AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78225-2244
Mailing Address - Country:US
Mailing Address - Phone:210-580-3316
Mailing Address - Fax:
Practice Address - Street 1:1431 W WINNIPEG AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78225-2244
Practice Address - Country:US
Practice Address - Phone:210-580-3316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-07
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX192472156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician