Healthcare Provider Details

I. General information

NPI: 1689253403
Provider Name (Legal Business Name): CAROLINA ELLINGER DA FONSECA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROLINA FONSECA

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 4TH ST
SAN FRANCISCO CA
94143-2351
US

IV. Provider business mailing address

22201 MOROSS RD STE 80
DETROIT MI
48236-2169
US

V. Phone/Fax

Practice location:
  • Phone: 415-514-4079
  • Fax:
Mailing address:
  • Phone: 313-343-3800
  • Fax: 313-343-4756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA196003
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351047788
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: