Provider Demographics
NPI:1972700714
Name:FONSECA, GUILLERMO ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:ANTONIO
Last Name: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 1:11880 SW 40TH ST
Mailing Address - Street 2:SUITE 318
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3584
Mailing Address - Country:US
Mailing Address - Phone:305-223-3989
Mailing Address - Fax:305-223-0145
Practice Address - Street 1:11880 SW 40TH ST
Practice Address - Street 2:SUITE 318
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3584
Practice Address - Country:US
Practice Address - Phone:305-223-3989
Practice Address - Fax:305-223-0145
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064061207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18842Medicare ID - Type Unspecified
FLF58236Medicare UPIN