Provider Demographics
NPI:1336860774
Name:FONSECA MILIAN, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:FONSECA MILIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 SW 84TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1051
Mailing Address - Country:US
Mailing Address - Phone:786-930-3761
Mailing Address - Fax:
Practice Address - Street 1:6850 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-5114
Practice Address - Country:US
Practice Address - Phone:786-930-3761
Practice Address - Fax:786-245-0751
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR022867261QP2300X
FL1499261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care