Provider Demographics
NPI:1750323713
Name:DE LA FUENTE, EDGAR (LICENSED PROSTHETIST)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:
Last Name:DE LA FUENTE
Suffix:
Gender:M
Credentials:LICENSED PROSTHETIST
Other - Prefix:
Other - First Name:DBA VRAI
Other - Middle Name:PROSTHETIC
Other - Last Name:CARE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:719 N. SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5316
Mailing Address - Country:US
Mailing Address - Phone:903-553-1040
Mailing Address - Fax:903-553-9996
Practice Address - Street 1:719 N. SECOND STREET
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5316
Practice Address - Country:US
Practice Address - Phone:903-553-1040
Practice Address - Fax:903-553-9996
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1750323713OtherNPI
TX531976OtherBCBS OF TEXAS
TX168459901Medicaid
TX531976OtherBCBS OF TEXAS