Healthcare Provider Details

I. General information

NPI: 1598741894
Provider Name (Legal Business Name): FERNANDO R PUENTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SPRINGFIELD COMMONS DR SUITE 115
RALEIGH NC
27609-8533
US

IV. Provider business mailing address

800 SPRINGFIELD COMMONS DR SUITE 115
RALEIGH NC
27609-8533
US

V. Phone/Fax

Practice location:
  • Phone: 919-876-3656
  • Fax: 919-876-2351
Mailing address:
  • Phone: 919-876-3656
  • Fax: 919-876-2351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number39984
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number39984
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: