Healthcare Provider Details

I. General information

NPI: 1992490544
Provider Name (Legal Business Name): JOSE GONZALO PUENTE MORENO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N CHERRY ST
TULARE CA
93274-2231
US

IV. Provider business mailing address

1201 N CHERRY ST
TULARE CA
93274-2233
US

V. Phone/Fax

Practice location:
  • Phone: 559-686-9097
  • Fax: 559-366-7060
Mailing address:
  • Phone: 559-686-9097
  • Fax: 559-366-7060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberP22
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: