Provider Demographics
NPI:1578217568
Name:VEGA FONSECA, GISELA
Entity type:Individual
Prefix:DR
First Name:GISELA
Middle Name:
Last Name:VEGA 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:COND. PASEO GALES 2501
Mailing Address - Street 2:CARR. 9189 APTD. 47
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:787-718-2812
Mailing Address - Fax:
Practice Address - Street 1:DIAZ BRETANA MEDICAL BUILDING 203
Practice Address - Street 2:CARR 183 KM 10.4
Practice Address - City:SAN LORENZO
Practice Address - State:PR
Practice Address - Zip Code:00754
Practice Address - Country:US
Practice Address - Phone:787-485-9953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR23201208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice