Individual
LUCIA FERNANDA FONTALVO-HERAZO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
34TH STREET AND CIVIC CENTER BLVD, PHILADELPHIA, PA 19104-6503
(215) 590-2575
(215) 590-5797
Mailing address
1900 S BROAD ST, PHILADELPHIA, PA 19145-2304
(215) 590-2575
(215) 590-5797
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
LT000622
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
PENDING
—
PA
Enumeration date
05/21/2007
Last updated
07/08/2007
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