Provider Demographics
NPI:1194168104
Name:DA FONSECA, CHRISTOPHER JORGE (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JORGE
Last Name:DA FONSECA
Suffix:
Gender:M
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:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-595-8080
Mailing Address - Fax:
Practice Address - Street 1:12314 SW 127TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6579
Practice Address - Country:US
Practice Address - Phone:786-595-8080
Practice Address - Fax:786-533-9381
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121862207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program