Provider Demographics
NPI:1639361033
Name:FUENTES, CARMEN ROXANA (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:ROXANA
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 1:6161 KEMPSVILLE CIR
Mailing Address - Street 2:SUITE 315
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3932
Mailing Address - Country:US
Mailing Address - Phone:757-461-5400
Mailing Address - Fax:757-461-3305
Practice Address - Street 1:6161 KEMPSVILLE CIR
Practice Address - Street 2:SUITE 315
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3932
Practice Address - Country:US
Practice Address - Phone:757-461-5400
Practice Address - Fax:757-461-3305
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2026622084N0400X
VA01012484442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07480774Medicaid
LA1507555Medicaid
LA4M2617061Medicare PIN
LA4M261Medicare PIN