Provider Demographics
NPI:1558793596
Name:FONSECA, VINCENT PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:PAUL
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 1:402 DONALDSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-4907
Mailing Address - Country:US
Mailing Address - Phone:210-279-8911
Mailing Address - Fax:
Practice Address - Street 1:4025 E SOUTHCROSS BLVD STE 15
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-3641
Practice Address - Country:US
Practice Address - Phone:210-610-7283
Practice Address - Fax:210-812-5938
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM79722083B0002X, 2083C0008X, 2083P0901X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
No2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine