Provider Demographics
NPI:1205824406
Name:FONSECA, LUVIANCA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LUVIANCA
Middle Name:J
Last Name:FONSECA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4255 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5041
Mailing Address - Country:US
Mailing Address - Phone:773-424-4048
Mailing Address - Fax:773-424-6463
Practice Address - Street 1:4255 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5041
Practice Address - Country:US
Practice Address - Phone:773-424-4048
Practice Address - Fax:773-424-6463
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105462Medicaid
K52393Medicare PIN