Provider Demographics
NPI:1831659879
Name:FONSECA MORA, MARIA CAMILA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:CAMILA
Last Name:FONSECA MORA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-5317
Mailing Address - Country:US
Mailing Address - Phone:917-213-0992
Mailing Address - Fax:
Practice Address - Street 1:1901 1ST AVE FL 11
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-7491
Practice Address - Country:US
Practice Address - Phone:212-423-6771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25673208600000X
390200000X
NY390200000X
NY333321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program