Healthcare Provider Details

I. General information

NPI: 1487855987
Provider Name (Legal Business Name): JUAN CARLOS FUENTES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2570 RACE TRACK RD
ST JOHNS FL
32259-4588
US

IV. Provider business mailing address

PO BOX 100237
GAINESVILLE FL
32610-0237
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-1005
  • Fax: 904-819-1002
Mailing address:
  • Phone: 904-819-1005
  • Fax: 904-819-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME99492
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: