Provider Demographics
NPI:1245569938
Name:FONSECA ORTIZ, NUBIA (MD)
Entity Type:Individual
Prefix:
First Name:NUBIA
Middle Name:
Last Name:FONSECA ORTIZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 S ATLANTIC AVE
Mailing Address - Street 2:AP 1804
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-5546
Mailing Address - Country:US
Mailing Address - Phone:347-571-4429
Mailing Address - Fax:
Practice Address - Street 1:301 MEMORIAL MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-231-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111318207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine