Provider Demographics
NPI:1487008025
Name:FONSECA, ALLENE
Entity Type:Individual
Prefix:
First Name:ALLENE
Middle Name:
Last Name:FONSECA
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 1:18100 OAKWOOD BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4085
Mailing Address - Country:US
Mailing Address - Phone:313-240-4900
Mailing Address - Fax:313-429-7992
Practice Address - Street 1:18100 OAKWOOD BLVD STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4085
Practice Address - Country:US
Practice Address - Phone:313-240-4900
Practice Address - Fax:313-429-7992
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351050138207N00000X
CAA150457207R00000X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine