Healthcare Provider Details

I. General information

NPI: 1407890841
Provider Name (Legal Business Name): LISA DE LAS FUENTES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12634 OLIVE BLVD DIV IM CARDIOLOGY
SAINT LOUIS MO
63141-6337
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1291
  • Fax: 314-747-1417
Mailing address:
  • Phone: 314-362-1291
  • Fax: 314-747-1417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2000160333
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: