Provider Demographics
NPI:1023309523
Name:CANDIDO FUENTES-FELIX PHYSICAN PC
Entity type:Organization
Organization Name:CANDIDO FUENTES-FELIX PHYSICAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDIDO
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES-FELIX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-385-9377
Mailing Address - Street 1:120 NEW YORK AVE
Mailing Address - Street 2:SUITE 1W
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2773
Mailing Address - Country:US
Mailing Address - Phone:631-385-9377
Mailing Address - Fax:
Practice Address - Street 1:120 NEW YORK AVE
Practice Address - Street 2:SUITE 1W
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2773
Practice Address - Country:US
Practice Address - Phone:631-385-9377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-02
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148869-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY46D543Medicare PIN