Provider Demographics
NPI:1447009741
Name:FONSECA, DEVORATH
Entity type:Individual
Prefix:
First Name:DEVORATH
Middle Name:
Last Name:FONSECA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 SW 97TH AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2680
Mailing Address - Country:US
Mailing Address - Phone:786-963-9155
Mailing Address - Fax:786-963-9181
Practice Address - Street 1:2720 SW 97TH AVE APT 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2680
Practice Address - Country:US
Practice Address - Phone:786-963-9155
Practice Address - Fax:786-963-9181
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment