=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447796339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUILLERMO A. FONSECA M.D., PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2017
-----------------------------------------------------
Last Update Date | 01/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14750 SW 26TH ST SUITE 212-214
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33185-5933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-223-3989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14750 SW 26TH ST SUITE 212-214
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33185-5933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-223-3989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GUILLERMO ANTONIO FONSECA
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 305-223-3989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME0064061
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------