Provider Demographics
NPI:1457718488
Name:FONSECA, JORGE LUIS
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:FONSECA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8825 N FAWN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-9291
Mailing Address - Country:US
Mailing Address - Phone:563-663-6392
Mailing Address - Fax:
Practice Address - Street 1:8825 N FAWN MEADOW DR
Practice Address - Street 2:
Practice Address - City:MCCORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-9291
Practice Address - Country:US
Practice Address - Phone:563-663-6392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer