Provider Demographics
NPI:1407890841
Name:DE LAS FUENTES, LISA (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:DE LAS FUENTES
Suffix:
Gender:
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:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-1291
Mailing Address - Fax:314-747-1417
Practice Address - Street 1:12634 OLIVE BLVD
Practice Address - Street 2:DIV IM CARDIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6337
Practice Address - Country:US
Practice Address - Phone:314-362-1291
Practice Address - Fax:314-747-1417
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160333207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206126906Medicaid
ILENROLLEDMedicaid
MO206126906Medicaid
MO905202057Medicare PIN
MO905200183Medicare PIN