Healthcare Provider Details

I. General information

NPI: 1962814558
Provider Name (Legal Business Name): PABLO ODELEY PUENTE FUMERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNION NORTE
SAN JUAN PR
00907-3455
US

IV. Provider business mailing address

4160 SW 97TH AVE
MIAMI FL
33165-5115
US

V. Phone/Fax

Practice location:
  • Phone: 305-333-4777
  • Fax:
Mailing address:
  • Phone: 305-333-4777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH14595
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3184
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: