MEDICARE: DR. GWEN CANARIAS FUENTES M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	13171	OK

General Provider Information

NPI Number	:	1013914324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GWEN CANARIAS FUENTES M.D.

Provider Business Mailing Address
First Line	:	919 15TH AVE NW
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1809
Country	:	US
Telephone Number	:	580-223-5693
Fax Number	:	580-223-8909

Provider Business Practice Location Address
First Line	:	919 15TH AVE NW
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1809
Country	:	US
Telephone Number	:	580-223-5693
Fax Number	:	580-223-8909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	07/09/2007

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