Healthcare Provider Details

I. General information

NPI: 1548470032
Provider Name (Legal Business Name): FE POBLETE FUENTES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 GRASSO PLZ
SAINT LOUIS MO
63123-3108
US

IV. Provider business mailing address

84 GRASSO PLZ
SAINT LOUIS MO
63123-3108
US

V. Phone/Fax

Practice location:
  • Phone: 314-638-9309
  • Fax: 314-638-9333
Mailing address:
  • Phone: 314-638-9309
  • Fax: 314-638-9333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35954
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: