Provider Demographics
NPI:1669647921
Name:DE LA FUENTE, SEBASTIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:
Last Name:DE LA FUENTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 N. ORANGE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804
Mailing Address - Country:US
Mailing Address - Phone:407-303-7399
Mailing Address - Fax:407-303-7305
Practice Address - Street 1:2415 N. ORANGE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804
Practice Address - Country:US
Practice Address - Phone:407-303-7399
Practice Address - Fax:407-303-7305
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC117167208600000X
FLME1069462086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002460700Medicaid
FLDL961YMedicare UPIN