Healthcare Provider Details

I. General information

NPI: 1891154860
Provider Name (Legal Business Name): MANUEL PUENTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 SIMMONS LOOP FL 4
RIVERVIEW FL
33578-9498
US

IV. Provider business mailing address

2995 DREW ST
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 813-302-8388
  • Fax: 813-302-8453
Mailing address:
  • Phone: 727-315-7496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMS0112615
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT210110
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: