MEDICARE: DR. LUVIANCA J. FONSECA M.D.

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	036105462	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205824406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUVIANCA J. FONSECA M.D.

Provider Business Mailing Address
First Line	:	4255 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-5041
Country	:	US
Telephone Number	:	773-424-4048
Fax Number	:	773-424-6463

Provider Business Practice Location Address
First Line	:	4255 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-5041
Country	:	US
Telephone Number	:	773-424-4048
Fax Number	:	773-424-6463

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	12/28/2021

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