Healthcare Provider Details

I. General information

NPI: 1942136502
Provider Name (Legal Business Name): MAGDALENA FUENTES OD PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 W SEPULVEDA BLVD
CARSON CA
90745-6314
US

IV. Provider business mailing address

651 W SEPULVEDA BLVD
CARSON CA
90745-6314
US

V. Phone/Fax

Practice location:
  • Phone: 310-547-6538
  • Fax:
Mailing address:
  • Phone: 310-547-6538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MAGDALENA FUENTES
Title or Position: OPTOMETRIST
Credential: OD
Phone: 310-908-2979