Provider Demographics
NPI:1679145858
Name:FONSECA RODRIGUEZ, RAFAEL ANTONIO (DC)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ANTONIO
Last Name:FONSECA RODRIGUEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE A E-12 ESTANCIAS DEL PARQUE
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-363-3033
Mailing Address - Fax:
Practice Address - Street 1:1825 CALLE NAVARRA STE 301
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4614
Practice Address - Country:US
Practice Address - Phone:787-789-1996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR861111N00000X
TX14357111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor