Healthcare Provider Details

I. General information

NPI: 1528350543
Provider Name (Legal Business Name): JORGE E FUENTES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 ALTON RD STE 2070
MIAMI BEACH FL
33140-2948
US

IV. Provider business mailing address

4300 ALTON RD STE 2070
MIAMI BEACH FL
33140-2948
US

V. Phone/Fax

Practice location:
  • Phone: 305-582-8015
  • Fax:
Mailing address:
  • Phone: 305-582-8015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME19476
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME119476
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME119476
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: