Provider Demographics
NPI:1417296930
Name:FUENTEBAJA, CARTER (D PT)
Entity Type:Individual
Prefix:MR
First Name:CARTER
Middle Name:
Last Name:FUENTEBAJA
Suffix:
Gender:M
Credentials:D PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5516 4TH AVE
Mailing Address - Street 2:APT 2L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3035
Mailing Address - Country:US
Mailing Address - Phone:347-309-3950
Mailing Address - Fax:
Practice Address - Street 1:2390 MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-4740
Practice Address - Country:US
Practice Address - Phone:718-449-1005
Practice Address - Fax:718-449-1131
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist