Provider Demographics
NPI:1376565408
Name:FONSECA, JOSE (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:FONSECA
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MORNING VIEW CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-2934
Mailing Address - Country:US
Mailing Address - Phone:919-596-5221
Mailing Address - Fax:
Practice Address - Street 1:DUKE UNIVERSITY
Practice Address - Street 2:118 CAMERON INDOOR STADIUM
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27708-0001
Practice Address - Country:US
Practice Address - Phone:919-613-7559
Practice Address - Fax:919-681-7866
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer