Healthcare Provider Details

I. General information

NPI: 1285976720
Provider Name (Legal Business Name): DESMOND FONJI D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 WELLNESS WAY STE 200
SEBASTIAN FL
32958-3783
US

IV. Provider business mailing address

902 CLINT MOORE RD
BOCA RATON FL
33487-2800
US

V. Phone/Fax

Practice location:
  • Phone: 772-581-5581
  • Fax: 772-581-5781
Mailing address:
  • Phone: 561-642-1000
  • Fax: 561-802-3976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS13298
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: