Healthcare Provider Details

I. General information

NPI: 1881475762
Provider Name (Legal Business Name): FONSECA PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 17TH ST UNIT 102
SAINT CLOUD FL
34769-4939
US

IV. Provider business mailing address

2801 17TH ST UNIT 102
SAINT CLOUD FL
34769-4939
US

V. Phone/Fax

Practice location:
  • Phone: 407-519-2930
  • Fax: 407-556-3565
Mailing address:
  • Phone: 407-519-2930
  • Fax: 407-556-3565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: RAMON AUGUSTO FONSECA
Title or Position: OWNER
Credential: MD
Phone: 407-729-6068