Provider Demographics
NPI:1285898288
Name:MENDOZA FONSECA, GUILLERMO ALFREDO (MD)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:ALFREDO
Last Name:MENDOZA 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 1:2572 W STATE ROAD 426 STE 3040
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8389
Mailing Address - Country:US
Mailing Address - Phone:407-890-9748
Mailing Address - Fax:407-890-9819
Practice Address - Street 1:2572 W STATE ROAD 426 STE 3040
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8389
Practice Address - Country:US
Practice Address - Phone:407-890-9748
Practice Address - Fax:407-890-9819
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117112207R00000X, 208D00000X
RIMD12761207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME117112OtherMEDICAL LICENSE
FL009890300Medicaid
FL009890300Medicaid
FLME117112OtherMEDICAL LICENSE
FLHP172VMedicare PIN
FLFM1039216OtherDEA
FLHP172WMedicare PIN