Provider Demographics
NPI:1992141147
Name:FONFARA, THEODORE JOHN (HAS)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:JOHN
Last Name:FONFARA
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 TAMIAMI TRL
Mailing Address - Street 2:STE.A
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5173
Mailing Address - Country:US
Mailing Address - Phone:941-629-8808
Mailing Address - Fax:941-629-1025
Practice Address - Street 1:2811 TAMIAMI TRL
Practice Address - Street 2:STE.A
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5173
Practice Address - Country:US
Practice Address - Phone:941-629-8808
Practice Address - Fax:941-629-1025
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS 3621237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist