Healthcare Provider Details

I. General information

NPI: 1104822683
Provider Name (Legal Business Name): CARMINA M FUSCO DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 MCCULLOUGH AVE 2ND FLOOR
SAN ANTONIO TX
78212-4046
US

IV. Provider business mailing address

1715 MCCULLOUGH AVE 2ND FLOOR
SAN ANTONIO TX
78212-4046
US

V. Phone/Fax

Practice location:
  • Phone: 210-732-3668
  • Fax: 201-732-3338
Mailing address:
  • Phone: 210-732-3668
  • Fax: 201-732-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number1812
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: