Healthcare Provider Details

I. General information

NPI: 1003201799
Provider Name (Legal Business Name): MAIRA FONSECA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

1275 YORK AVE # 8
NEW YORK NY
10065-6007
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-3210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number300446
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: