Healthcare Provider Details

I. General information

NPI: 1396101028
Provider Name (Legal Business Name): MARK FONSECA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3143 W JEFFERSON ST
JOLIET IL
60435-4733
US

IV. Provider business mailing address

215 SHUMAN BLVD STE 401
NAPERVILLE IL
60563-8458
US

V. Phone/Fax

Practice location:
  • Phone: 815-744-6898
  • Fax: 815-744-2486
Mailing address:
  • Phone: 630-303-5380
  • Fax: 978-313-6824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3016
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: