Healthcare Provider Details

I. General information

NPI: 1801008396
Provider Name (Legal Business Name): PETER FONSECA MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 01/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY SUITE 345A
ST. LOUIS MO
63128
US

IV. Provider business mailing address

10004 KENNERLY SUITE 345A
ST. LOUIS MO
63128
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5252
  • Fax: 314-543-5211
Mailing address:
  • Phone: 314-543-5252
  • Fax: 314-543-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number116658
License Number StateMO

VIII. Authorized Official

Name: DR. PETER FONSECA
Title or Position: PRESIDENT
Credential: MD
Phone: 314-543-5252