Basic Information
Provider Information | |||||||||
NPI: | 1093829400 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FONSECA | ||||||||
FirstName: | JESUS | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 NORTH MAIN | ||||||||
Address2: |   | ||||||||
City: | LOVINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 882602830 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5753966611 | ||||||||
FaxNumber: | 5753961454 | ||||||||
Practice Location | |||||||||
Address1: | 1923 N. DAL PASO, SUITE A | ||||||||
Address2: | HOBBS MEDICAL CLINIC | ||||||||
City: | HOBBS | ||||||||
State: | NM | ||||||||
PostalCode: | 882403023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5754333000 | ||||||||
FaxNumber: | 5754334451 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2006 | ||||||||
LastUpdateDate: | 03/08/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2001-192 | NM | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | G2204 | 05 | NM |   | MEDICAID |