Basic Information
| Provider Information | |||||||||
| NPI: | 1245569938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONSECA ORTIZ | ||||||||
| FirstName: | NUBIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 S ATLANTIC AVE | ||||||||
| Address2: | AP 1804 | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321185546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3475714429 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 MEMORIAL MEDICAL PARKWAY | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321175167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862316000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2009 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME111318 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.