Provider Demographics
NPI:1487030417
Name:FUENTES, LUIS III (DO)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
Last Name:FUENTES
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1641 NILE DR APT 422
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-4965
Mailing Address - Country:US
Mailing Address - Phone:956-236-5477
Mailing Address - Fax:
Practice Address - Street 1:4818 HOLLY RD STE A
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411
Practice Address - Country:US
Practice Address - Phone:361-993-1747
Practice Address - Fax:361-993-1748
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10053714208D00000X
TXR8190208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice