Healthcare Provider Details

I. General information

NPI: 1508153297
Provider Name (Legal Business Name): MARIA GERALDINA FUENTES MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 3RD AVE
CHULA VISTA CA
91910-5803
US

IV. Provider business mailing address

717 3RD AVE
CHULA VISTA CA
91910-5803
US

V. Phone/Fax

Practice location:
  • Phone: 619-941-1545
  • Fax: 619-941-1558
Mailing address:
  • Phone: 619-941-1545
  • Fax: 619-941-1558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA83896
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA GERALDINA FUENTES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-941-1545