Provider Demographics
NPI:1063478766
Name:FONSECA, GUSTAVO A (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:A
Last Name:FONSECA
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Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:521 N LECANTO HWY
Practice Address - Street 2:FLORIDA CANCER SPECIALISTS P L
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-9187
Practice Address - Country:US
Practice Address - Phone:352-746-0707
Practice Address - Fax:352-746-6333
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2022-05-02
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Provider Licenses
StateLicense IDTaxonomies
FLME57124207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064874400Medicaid
FLE62246Medicare PIN
E62246Medicare UPIN