Provider Demographics
NPI:1760889182
Name:FONSECA FUENTES, XAVIER
Entity Type:Individual
Prefix:
First Name:XAVIER
Middle Name:
Last Name:FONSECA FUENTES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:XAVIER
Other - Middle Name:
Other - Last Name:FONSECA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:800-653-6568
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:800-653-6568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN60745207RP1001X, 207RC0200X
MI4301507390207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease