Provider Demographics
NPI:1114412160
Name:FUENTES, DAVID B
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:FUENTES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:BAZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC, CSCS
Mailing Address - Street 1:2904 WALL AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-3563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2904 WALL AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087
Practice Address - Country:US
Practice Address - Phone:847-791-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer