Provider Demographics
NPI:1578799748
Name:DA FONSECA, CARLOS RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:RAFAEL
Last Name:DA 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 1:2901 W TOUHY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2937
Mailing Address - Country:US
Mailing Address - Phone:773-973-7350
Mailing Address - Fax:773-973-0506
Practice Address - Street 1:2901 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-2937
Practice Address - Country:US
Practice Address - Phone:773-973-7350
Practice Address - Fax:773-973-0506
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-122089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine