Provider Demographics
NPI:1013666320
Name:FONCERRADA ORTEGA, GUILLERMO (MMS)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:
Last Name:FONCERRADA ORTEGA
Suffix:
Gender:M
Credentials:MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 CADILLAC DR APT 35
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-5444
Mailing Address - Country:US
Mailing Address - Phone:409-789-4756
Mailing Address - Fax:
Practice Address - Street 1:340 CADILLAC DR APT 35
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-5444
Practice Address - Country:US
Practice Address - Phone:409-789-4756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty