Provider Demographics
NPI:1477655611
Name:FONSECA RIVERA, MANUELA A
Entity Type:Individual
Prefix:
First Name:MANUELA
Middle Name:A
Last Name:FONSECA RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB PACIFICA P6 121
Mailing Address - Street 2:VIA ARCOIRIS ENCANTADA
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-755-8786
Mailing Address - Fax:787-758-1718
Practice Address - Street 1:CALLE GEORGETTI #122
Practice Address - Street 2:AMBULATORY MEDICAL SERVICES
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00925
Practice Address - Country:US
Practice Address - Phone:787-758-1718
Practice Address - Fax:787-758-1718
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRBF2810871208D00000X
PRDM097915208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice