Provider Demographics
NPI:1134535198
Name:ILEANA FUENTES MD, PA
Entity type:Organization
Organization Name:ILEANA FUENTES MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ILEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-588-4290
Mailing Address - Street 1:3150 SW 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2450
Mailing Address - Country:US
Mailing Address - Phone:305-588-4290
Mailing Address - Fax:
Practice Address - Street 1:4343 W FLAGLER ST STE 210
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1586
Practice Address - Country:US
Practice Address - Phone:305-588-4290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75683208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty