Provider Demographics
NPI:1790769396
Name:FONSECA, MANUEL ANTONIO (DO)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:ANTONIO
Last Name:FONSECA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23321
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-3321
Mailing Address - Country:US
Mailing Address - Phone:843-679-4214
Mailing Address - Fax:
Practice Address - Street 1:1925 HOFFMEYER RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4011
Practice Address - Country:US
Practice Address - Phone:843-679-4214
Practice Address - Fax:843-674-5146
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC004195Medicaid
SC004195Medicaid
SCF080657153Medicare PIN