Healthcare Provider Details

I. General information

NPI: 1730493198
Provider Name (Legal Business Name): SERGIO A. FUENZALIDA MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 S ATLANTIC BLVD SUITE 103
MONTEREY PARK CA
91754-6703
US

IV. Provider business mailing address

850 S ATLANTIC BLVD SUITE 103
MONTEREY PARK CA
91754-4730
US

V. Phone/Fax

Practice location:
  • Phone: 626-576-7481
  • Fax:
Mailing address:
  • Phone: 626-576-7481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA25157
License Number StateCA

VIII. Authorized Official

Name: SERGIO A FUENZALIDA
Title or Position: OWNER
Credential: M.D.
Phone: 626-576-7481