Provider Demographics
NPI:1093366064
Name:FYNN, RICHARD BONSRA (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BONSRA
Last Name:FYNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 WAYBOURNE WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6439
Mailing Address - Country:US
Mailing Address - Phone:732-895-8758
Mailing Address - Fax:
Practice Address - Street 1:907 WAYBOURNE WAY
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-6439
Practice Address - Country:US
Practice Address - Phone:732-895-8758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-21
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-379246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant