Healthcare Provider Details

I. General information

NPI: 1972664795
Provider Name (Legal Business Name): JUDY FUENTEBELLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PASTEUR DR SUMC - PEDS PHYSICIAN BILLING MC: 5530
STANFORD CA
94305-2200
US

IV. Provider business mailing address

300 PASTEUR DR SUMC - PEDS PHYSICIAN BILLING MC: 5530
STANFORD CA
94305-2200
US

V. Phone/Fax

Practice location:
  • Phone: 650-498-7391
  • Fax: 650-725-7888
Mailing address:
  • Phone: 650-498-7391
  • Fax: 650-725-7888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036116301
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA99709
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberA99709
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: