Provider Demographics
NPI:1699334458
Name:FUENTES, PHILIP (HIS)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:FUENTES
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CAMELLIA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-4657
Mailing Address - Country:US
Mailing Address - Phone:800-392-1041
Mailing Address - Fax:
Practice Address - Street 1:417 SAINT GEORGE ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3541
Practice Address - Country:US
Practice Address - Phone:800-392-1041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80683237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist