MEDICARE: CLINISANITAS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1013395755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINISANITAS, PC

Provider Business Mailing Address
First Line	:	8400 NW 33RD ST
Second Line	:	SUITE 100
City	:	DORAL
State	:	FL
Zip	:	33122-1937
Country	:	US
Telephone Number	:	305-921-7621
Fax Number	:	305-921-7355

Provider Business Practice Location Address
First Line	:	4543 MAIN ST
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06606-1818
Country	:	US
Telephone Number	:	305-921-7621
Fax Number	:	305-921-7355

Authorized Official
Title or Position	:	CEO
Name	:	DR. FERNANDO FONSECA
Credential	:	M.D.
Telephone Number	:	305-921-7621

Provider Enumeration Date	:	05/14/2015
Last Update Date	:	09/23/2016

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