Provider Demographics
NPI:1487839700
Name:PUENTES, MARIA DE LOS ANGELES
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:DE LOS ANGELES
Last Name:PUENTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16919 N BAY RD APT 918
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4220
Mailing Address - Country:US
Mailing Address - Phone:786-333-7402
Mailing Address - Fax:305-945-5134
Practice Address - Street 1:16919 N BAY RD APT 918
Practice Address - Street 2:
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-4220
Practice Address - Country:US
Practice Address - Phone:786-333-7402
Practice Address - Fax:305-945-5134
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-05
Last Update Date:2008-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6931341 96171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6931341 96Medicaid