Provider Demographics
NPI:1477864825
Name:MICHAEL G FUENTES MD PA
Entity Type:Organization
Organization Name:MICHAEL G FUENTES MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-888-7716
Mailing Address - Street 1:5656 S STAPLES ST
Mailing Address - Street 2:SUITE 252
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4693
Mailing Address - Country:US
Mailing Address - Phone:361-888-7716
Mailing Address - Fax:
Practice Address - Street 1:5656 S STAPLES ST
Practice Address - Street 2:SUITE 252
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4693
Practice Address - Country:US
Practice Address - Phone:361-888-7716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4062208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1689721383OtherNPI
TXK4062OtherLICENSE
TXTXB109235Medicare PIN
TXK4062OtherLICENSE
TX0034CAMedicare PIN