Provider Demographics
NPI:1598829137
Name:ERNESTO FUENTES MD PA
Entity Type:Organization
Organization Name:ERNESTO FUENTES MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:954-687-9745
Mailing Address - Street 1:2114 N FLAMINGO RD
Mailing Address - Street 2:STE 306
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-3501
Mailing Address - Country:US
Mailing Address - Phone:954-687-9745
Mailing Address - Fax:954-666-0668
Practice Address - Street 1:601 N FLAMINGO RD
Practice Address - Street 2:SUITE 400
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1015
Practice Address - Country:US
Practice Address - Phone:954-687-9745
Practice Address - Fax:954-666-0668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251312900Medicaid
FL32821AMedicare ID - Type Unspecified
FL251312900Medicaid