Provider Demographics
NPI:1679554430
Name:FUENTEVILLA, ANA (MD)
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:
Last Name:FUENTEVILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E 7TH ST STE 700
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-3218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 W WILLIAM CANNON DR STE 205
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5288
Practice Address - Country:US
Practice Address - Phone:512-548-0465
Practice Address - Fax:737-707-3908
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT9687207RG0300X
AZ18893207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ110643Medicaid
AZ110643Medicaid
AZ74462Medicare ID - Type Unspecified