Provider Demographics
NPI:1104580208
Name:DOCTOR FUENTES HEALTHCARE
Entity type:Organization
Organization Name:DOCTOR FUENTES HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SADYS
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-502-1026
Mailing Address - Street 1:1932 SW 142ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-7088
Mailing Address - Country:US
Mailing Address - Phone:786-502-1026
Mailing Address - Fax:
Practice Address - Street 1:1932 SW 142ND CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-7088
Practice Address - Country:US
Practice Address - Phone:786-502-1026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-25
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLICENSEOther147155