Healthcare Provider Details

I. General information

NPI: 1528116365
Provider Name (Legal Business Name): MARYLUZ FUENTES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 TAYLOR RD SUITE 310
MONTGOMERY AL
36117-3563
US

IV. Provider business mailing address

301 BROWN SPRINGS RD
MONTGOMERY AL
36117-7005
US

V. Phone/Fax

Practice location:
  • Phone: 334-244-4322
  • Fax: 334-244-4321
Mailing address:
  • Phone: 334-273-4508
  • Fax: 334-273-4290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME131656
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA10365200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD466152
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042.0014217
License Number StateVT
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number296818
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number276775
License Number StateMA
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00024127
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: