Basic Information
| Provider Information | |||||||||
| NPI: | 1952410821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOUNTILA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2121 E GRIFFIN PKWY | ||||||||
| Address2: | SUITE 12 | ||||||||
| City: | MISSION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785723241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565810303 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1401 E 8TH ST | ||||||||
| Address2: | |||||||||
| City: | WESLACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785966640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565810303 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | L6896 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.