1013933506 NPI number — WALSTIR H FONSECA MD

Table of content: WALSTIR H FONSECA MD (NPI 1013933506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013933506 NPI number — WALSTIR H FONSECA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONSECA
Provider First Name:
WALSTIR
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013933506
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
76 S KINGS PEAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINDON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84042-2223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-370-5193
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
76 S KINGS PEAK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINDON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84042-2223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-370-5193
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  329175-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04-00322 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 110166693 . This is a "PALMETTO" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM0000000074 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 286636 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 46639 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870281028FO1 . This is a "EMIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107007883101 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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