Healthcare Provider Details

I. General information

NPI: 1013914324
Provider Name (Legal Business Name): GWEN CANARIAS FUENTES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 15TH AVE NW
ARDMORE OK
73401-1809
US

IV. Provider business mailing address

919 15TH AVE NW
ARDMORE OK
73401-1809
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-5693
  • Fax: 580-223-8909
Mailing address:
  • Phone: 580-223-5693
  • Fax: 580-223-8909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13171
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: