Provider Demographics
NPI:1962599571
Name:FUENTES, GUILLERMO MARTIN (DO)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:MARTIN
Last Name:FUENTES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N JOSEY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-6145
Mailing Address - Country:US
Mailing Address - Phone:972-242-2726
Mailing Address - Fax:972-242-5266
Practice Address - Street 1:1205 N JOSEY LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-6145
Practice Address - Country:US
Practice Address - Phone:972-242-2726
Practice Address - Fax:972-242-5266
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7327110OtherAETNA ID
TXK8749OtherTX-LICENSE
TX9818OtherPARKLAND ID
TX039181502OtherTPI
TX10031886OtherAMERIGROUP
TX147634301Medicaid
TX8F0700OtherBLUECROSSBLUESHIELD
TXK8749OtherTX-LICENSE