Healthcare Provider Details

I. General information

NPI: 1942860614
Provider Name (Legal Business Name): JOSHUA FONSECA BOLANOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2019
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIRCLIFF WAY
JACKSONVILLE FL
32204-4748
US

IV. Provider business mailing address

1 SHIRCLIFF WAY
JACKSONVILLE FL
32204-4748
US

V. Phone/Fax

Practice location:
  • Phone: 954-939-6636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME161030
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number280081
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: