Provider Demographics
NPI:1336295997
Name:PUENTES, STEPHEN MARK (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:PUENTES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8902 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6401
Mailing Address - Country:US
Mailing Address - Phone:818-830-7033
Mailing Address - Fax:818-830-7280
Practice Address - Street 1:5850 S MAIN ST
Practice Address - Street 2:ROOM 1127
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1215
Practice Address - Country:US
Practice Address - Phone:323-846-4219
Practice Address - Fax:323-238-0210
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2010-03-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG63475207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70769FMedicaid
CA952662606OtherTAX ID EPDB GROUP
CAFHC70468FMedicaid
CAG063475OtherMEDICAL LICENSE
CAFHC 11866 FMedicaid
CAFHC70769FMedicaid
CA952662606OtherTAX ID EPDB GROUP
CAFHC70468FMedicaid