Healthcare Provider Details

I. General information

NPI: 1043218050
Provider Name (Legal Business Name): HENRY J FUENTES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 W COLLEGE DR
PALOS HEIGHTS IL
60463-1001
US

IV. Provider business mailing address

7600 W COLLEGE DR
PALOS HEIGHTS IL
60463-1001
US

V. Phone/Fax

Practice location:
  • Phone: 708-361-0600
  • Fax: 708-923-2529
Mailing address:
  • Phone: 708-361-0600
  • Fax: 708-923-2529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number01040355A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036070990
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: