Healthcare Provider Details

I. General information

NPI: 1568105443
Provider Name (Legal Business Name): ELVIS FONJUNGO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457-7606
US

IV. Provider business mailing address

610 SOLAREX CT
FREDERICK MD
21703-8624
US

V. Phone/Fax

Practice location:
  • Phone: 718-901-8203
  • Fax:
Mailing address:
  • Phone: 443-388-4734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0104402
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: