Healthcare Provider Details

I. General information

NPI: 1124082003
Provider Name (Legal Business Name): MARIO J FONSECA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7325 SW 63RD AVE SUITE 201
SOUTH MIAMI FL
33143-4811
US

IV. Provider business mailing address

6630 SW 77TH TER
SOUTH MIAMI FL
33143-4634
US

V. Phone/Fax

Practice location:
  • Phone: 305-669-9404
  • Fax: 305-669-9660
Mailing address:
  • Phone: 305-669-9404
  • Fax: 305-669-9660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number65287
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: