Provider Demographics
NPI:1356512578
Name:FUENMAYOR, MARIELA JOSEFINA (MD)
Entity type:Individual
Prefix:
First Name:MARIELA
Middle Name:JOSEFINA
Last Name:FUENMAYOR
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 1:7500 RIALTO BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8556
Mailing Address - Country:US
Mailing Address - Phone:512-221-1029
Mailing Address - Fax:512-467-2502
Practice Address - Street 1:9015 MURRAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3675
Practice Address - Country:US
Practice Address - Phone:408-842-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-132532084P0800X
TXB0000261QM0850X
CAC1688412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health