Healthcare Provider Details

I. General information

NPI: 1831289594
Provider Name (Legal Business Name): LORRAINE FUENTES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18590 NW 67TH AVE SUITE # 101
HIALEAH FL
33015-3306
US

IV. Provider business mailing address

PO BOX 566417
MIAMI FL
33256-6417
US

V. Phone/Fax

Practice location:
  • Phone: 305-819-8633
  • Fax: 305-819-8630
Mailing address:
  • Phone: 305-819-8633
  • Fax: 305-819-8630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3954626
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: