Provider Demographics
NPI:1730493198
Name:SERGIO A. FUENZALIDA MD INC.
Entity Type:Organization
Organization Name:SERGIO A. FUENZALIDA MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:FUENZALIDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-576-7481
Mailing Address - Street 1:850 S ATLANTIC BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4730
Mailing Address - Country:US
Mailing Address - Phone:626-576-7481
Mailing Address - Fax:
Practice Address - Street 1:850 S ATLANTIC BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-6703
Practice Address - Country:US
Practice Address - Phone:626-576-7481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-27
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA251572084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A251570Medicaid
CAA25157Medicare PIN
CAA83184Medicare UPIN