Provider Demographics
NPI:1891802880
Name:FENTON, ALEXIS MAGUIN (MD)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MAGUIN
Last Name:FENTON
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 1:1150 N LOOP 1604 W # 108-645
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-4552
Mailing Address - Country:US
Mailing Address - Phone:210-332-3524
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-4552
Practice Address - Country:US
Practice Address - Phone:859-323-0295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP339207RC0000X, 207RC0001X
TXL1571207RC0000X, 207RC0001X
NMMD2018-0640207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141194406Medicaid
TX141194406Medicaid