Provider Demographics
NPI:1881475762
Name:FONSECA PEDIATRICS LLC
Entity type:Organization
Organization Name:FONSECA PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:AUGUSTO
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-729-6068
Mailing Address - Street 1:2801 17TH ST UNIT 102
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4939
Mailing Address - Country:US
Mailing Address - Phone:407-519-2930
Mailing Address - Fax:407-556-3565
Practice Address - Street 1:2801 17TH ST UNIT 102
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4939
Practice Address - Country:US
Practice Address - Phone:407-519-2930
Practice Address - Fax:407-556-3565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV95A6OtherBLUE CROSS BLUE SHIELD NUMBER
FL120425200Medicaid