Healthcare Provider Details

I. General information

NPI: 1558793596
Provider Name (Legal Business Name): VINCENT PAUL FONSECA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 E SOUTHCROSS BLVD STE 15
SAN ANTONIO TX
78222-3641
US

IV. Provider business mailing address

402 DONALDSON AVE
SAN ANTONIO TX
78201-4907
US

V. Phone/Fax

Practice location:
  • Phone: 210-610-7283
  • Fax: 210-812-5938
Mailing address:
  • Phone: 210-279-8911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License NumberM7972
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License NumberM7972
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberM7972
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM7972
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: