Provider Demographics
NPI:1023594751
Name:FANTAUZZI, JUAN CARLOS (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:FANTAUZZI
Suffix:
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:PO BOX 929
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662
Mailing Address - Country:US
Mailing Address - Phone:787-234-3729
Mailing Address - Fax:
Practice Address - Street 1:CARR 112 INT
Practice Address - Street 2:BO BEJUCOS SECT FLORIDA
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662
Practice Address - Country:US
Practice Address - Phone:787-234-3729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21022208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty