Provider Demographics
NPI:1265443410
Name:FONSECA, OLIMPO FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:OLIMPO
Middle Name:FERNANDO
Last Name:FONSECA
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:RR 3
Mailing Address - Street 2:
Mailing Address - City:BIGSTONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219
Mailing Address - Country:US
Mailing Address - Phone:276-523-1878
Mailing Address - Fax:
Practice Address - Street 1:134 CECIL D QUILLEN DR
Practice Address - Street 2:
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:24244-9726
Practice Address - Country:US
Practice Address - Phone:276-431-1638
Practice Address - Fax:276-431-1639
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031676207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB05511Medicare UPIN