Healthcare Provider Details

I. General information

NPI: 1831659879
Provider Name (Legal Business Name): MARIA CAMILA FONSECA MORA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 03/29/2025
Certification Date: 03/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE FL 11
NEW YORK NY
10029-7491
US

IV. Provider business mailing address

760 BROADWAY
BROOKLYN NY
11206-5317
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6771
  • Fax:
Mailing address:
  • Phone: 917-213-0992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25673
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number333321
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: