Provider Demographics
NPI:1801199393
Name:FONSECA, JESUS R (MA)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:R
Last Name:FONSECA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8260 W FLAGLER ST STE 1E
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2069
Mailing Address - Country:US
Mailing Address - Phone:305-746-8504
Mailing Address - Fax:
Practice Address - Street 1:8260 W FLAGLER ST STE 1E
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2069
Practice Address - Country:US
Practice Address - Phone:305-746-8504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy