Provider Demographics
NPI:1831289594
Name:FUENTES, LORRAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:LORRAINE
Middle Name:
Last Name:FUENTES
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:PO BOX 566417
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33256-6417
Mailing Address - Country:US
Mailing Address - Phone:305-819-8633
Mailing Address - Fax:305-819-8630
Practice Address - Street 1:18590 NW 67TH AVE
Practice Address - Street 2:SUITE # 101
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-3306
Practice Address - Country:US
Practice Address - Phone:305-819-8633
Practice Address - Fax:305-819-8630
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3954626208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374515500Medicaid
DEF76242Medicare UPIN