Provider Demographics
NPI:1396931135
Name:FONSECA, WANDA (MD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:
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 1:21 CALLE ONICE
Mailing Address - Street 2:URB. VILLA BLANCA
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-2065
Mailing Address - Country:US
Mailing Address - Phone:787-743-8411
Mailing Address - Fax:
Practice Address - Street 1:21 CALLE ONICE
Practice Address - Street 2:URB. VILLA BLANCA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-2065
Practice Address - Country:US
Practice Address - Phone:787-743-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10401208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice