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General NPI Number Information
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NPI Number | 1548985443
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Entity Type | Individual
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Provider Name | MICKEY FUENTES HOUSE PHYSICIAN-MD
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Gender | Male
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Dates
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Enumeration Date | 10/04/2022
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Last Update Date | 10/04/2022
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Provider Practice Location Address
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Address Line | 4300 ALTON RD
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City | MIAMI BEACH
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State | FL
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Zip | 33140-2948
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Country | US
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Telephone | 305-674-2310
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Fax |
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Provider Business Mailing Address
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Address Line | 10820 W 33RD WAY
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City | HIALEAH
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State | FL
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Zip | 33018-2194
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Country | US
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Telephone | 786-338-8754
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | HSE36496
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License Number State | FL
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