Provider Demographics
NPI:1386748077
Name:LAFONTAINE, EZEQUIEL SR (MD)
Entity type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:
Last Name:LAFONTAINE
Suffix:SR
Gender:M
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:LLANURAS DK 11
Mailing Address - Street 2:RIO HONDO 4
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961
Mailing Address - Country:US
Mailing Address - Phone:787-794-4718
Mailing Address - Fax:787-794-4718
Practice Address - Street 1:BARRIO INGENIO II 180
Practice Address - Street 2:
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:787-794-4718
Practice Address - Fax:787-794-4718
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13831208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20677Medicare ID - Type Unspecified
H44638Medicare UPIN