Provider Demographics
NPI:1124082003
Name:FONSECA, MARIO J (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:J
Last Name:FONSECA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 SW 77TH TER
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4634
Mailing Address - Country:US
Mailing Address - Phone:305-669-9404
Mailing Address - Fax:305-669-9660
Practice Address - Street 1:7325 SW 63RD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4811
Practice Address - Country:US
Practice Address - Phone:305-669-9404
Practice Address - Fax:305-669-9660
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL65287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23840OtherBCBSF
FL374540600Medicaid
FL23840ZMedicare PIN
FL23840OtherBCBSF