Provider Demographics
NPI:1922072750
Name:DE LA FUENTE, RONALD F (OD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:F
Last Name:DE LA FUENTE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 GARDENIA LN
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-4669
Mailing Address - Country:US
Mailing Address - Phone:972-540-9565
Mailing Address - Fax:214-379-2281
Practice Address - Street 1:1145 14TH ST
Practice Address - Street 2:SUITE 2115
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6201
Practice Address - Country:US
Practice Address - Phone:972-424-7236
Practice Address - Fax:972-423-0614
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5936TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176230401Medicaid
TX176230401Medicaid
TX8D7681Medicare ID - Type Unspecified
TXV02471Medicare UPIN