=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083830608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GWEN FUENTES MD PEDIATRIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 01/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 919 15TH AVE NW
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-5693
-----------------------------------------------------
Fax | 580-223-8909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 919 15TH AVE NW
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-5693
-----------------------------------------------------
Fax | 580-223-8909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GWEN CANARIAS FUENTES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 580-223-5693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 13171
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 13171
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------