Provider Demographics
NPI:1508153297
Name:MARIA GERALDINA FUENTES MD INC
Entity Type:Organization
Organization Name:MARIA GERALDINA FUENTES MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:GERALDINA
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-941-1545
Mailing Address - Street 1:717 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5803
Mailing Address - Country:US
Mailing Address - Phone:619-941-1545
Mailing Address - Fax:619-941-1558
Practice Address - Street 1:717 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5803
Practice Address - Country:US
Practice Address - Phone:619-941-1545
Practice Address - Fax:619-941-1558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83896207Q00000X
207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA83896Medicaid