Provider Demographics
NPI:1194540047
Name:FONTANILLS RIVERO, PEDRO ANTONIO (SA-C)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:ANTONIO
Last Name:FONTANILLS RIVERO
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16385 SW 302ND ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3350
Mailing Address - Country:US
Mailing Address - Phone:305-389-8282
Mailing Address - Fax:
Practice Address - Street 1:16385 SW 302ND ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-3350
Practice Address - Country:US
Practice Address - Phone:305-389-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-16
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-496246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant