Provider Demographics
NPI:1538523535
Name:FONTANEZ, OMAR R
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:R
Last Name:FONTANEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CALLE JUAN P DUARTE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917-3602
Mailing Address - Country:US
Mailing Address - Phone:787-433-2199
Mailing Address - Fax:
Practice Address - Street 1:200 CALLE JUAN P DUARTE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-3602
Practice Address - Country:US
Practice Address - Phone:787-433-2199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR723152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist