Provider Demographics
NPI:1063590230
Name:FUENTES, CANDIDO E (MD)
Entity type:Individual
Prefix:DR
First Name:CANDIDO
Middle Name:E
Last Name:FUENTES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 NEW YORK AVE
Mailing Address - Street 2:1W
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2743
Mailing Address - Country:US
Mailing Address - Phone:631-385-9377
Mailing Address - Fax:631-385-4372
Practice Address - Street 1:120 NEW YORK AVE
Practice Address - Street 2:1W
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2743
Practice Address - Country:US
Practice Address - Phone:631-385-9377
Practice Address - Fax:631-385-4372
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148869174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY46D543Medicare ID - Type Unspecified
NYA62859Medicare UPIN