Healthcare Provider Details

I. General information

NPI: 1760415293
Provider Name (Legal Business Name): GLORIA FUENTES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 W ROLLING CROSSROADS SUITE 100
BALTIMORE MD
21228-6280
US

IV. Provider business mailing address

1829 REISTERSTOWN RD SUITE 205
BALTIMORE MD
21208-6320
US

V. Phone/Fax

Practice location:
  • Phone: 410-869-0100
  • Fax: 410-869-0460
Mailing address:
  • Phone: 410-602-9842
  • Fax: 410-602-9857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0033157
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: