Provider Demographics
NPI:1790769396
Name:FONSECA, MANUEL ANTONIO (DO)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:ANTONIO
Last Name:FONSECA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:947 S IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5238
Mailing Address - Country:US
Mailing Address - Phone:843-674-5143
Mailing Address - Fax:843-674-5146
Practice Address - Street 1:805 PAMPLICO HWY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6047
Practice Address - Country:US
Practice Address - Phone:843-674-5143
Practice Address - Fax:843-674-5146
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC419207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC004195Medicaid
SC004195Medicaid
SCF080657153Medicare PIN