Provider Demographics
NPI:1013933506
Name:FONSECA, WALSTIR H (MD)
Entity Type:Individual
Prefix:
First Name:WALSTIR
Middle Name:H
Last Name:FONSECA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 S KINGS PEAK DR
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-2223
Mailing Address - Country:US
Mailing Address - Phone:801-370-5193
Mailing Address - Fax:
Practice Address - Street 1:76 S KINGS PEAK DR
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-2223
Practice Address - Country:US
Practice Address - Phone:801-370-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT329175-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT04-00322OtherUNITED HEALTHCARE
UT110166693OtherPALMETTO
UTQM0000000074OtherALTIUS
UT286636OtherDMBA
UT46639OtherPEHP
UT870281028FO1OtherEMIA
UT107007883101OtherIHC
UT870281028FO1OtherEMIA
UT107007883101OtherIHC
UT005502505Medicare ID - Type UnspecifiedMEDICARE
UT870281028000Medicaid