Provider Demographics
NPI:1285654319
Name:FUENTES, JOSE N (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:N
Last Name:FUENTES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11616 LAKE UNDERHILL RD STE 215
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-4465
Mailing Address - Country:US
Mailing Address - Phone:407-482-7788
Mailing Address - Fax:407-482-8698
Practice Address - Street 1:11616 LAKE UNDERHILL RD STE 205
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4466
Practice Address - Country:US
Practice Address - Phone:407-601-5308
Practice Address - Fax:407-482-8698
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME137036207R00000X, 207R00000X
PAMD058269L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6693903Medicaid
G15860Medicare UPIN
NJ6693903Medicaid