Healthcare Provider Details

I. General information

NPI: 1962814558
Provider Name (Legal Business Name): PABLO ODELEY PUENTE FUMERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 MILAN AVE
CORAL GABLES FL
33134-3504
US

IV. Provider business mailing address

AVE PABLO NERUDA 57 10-F
MADRID MADRID
28018
ES

V. Phone/Fax

Practice location:
  • Phone: 703-501-8550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH14595
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberIMH14595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: