Provider Demographics
NPI:1184641987
Name:FUENTES-VALDES, JOHANNA C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:C
Last Name:FUENTES-VALDES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:C
Other - Last Name:FUENTES-DAZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2801 K ST STE 502
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5119
Practice Address - Country:US
Practice Address - Phone:916-887-4660
Practice Address - Fax:916-887-4661
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8471315-1205207R00000X
CAC137378207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI17150Medicare UPIN