Provider Demographics
NPI:1649266461
Name:FUENTES, ERNESTO (MD)
Entity type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:
Last Name:FUENTES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 N FLAMINGO RD
Mailing Address - Street 2:STE 306
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-3501
Mailing Address - Country:US
Mailing Address - Phone:954-687-9745
Mailing Address - Fax:954-666-0668
Practice Address - Street 1:601 N FLAMINGO RD
Practice Address - Street 2:SUITE 400
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1015
Practice Address - Country:US
Practice Address - Phone:954-687-9745
Practice Address - Fax:954-666-0668
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69147207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251312900Medicaid
FL251312900Medicaid
FL32821AMedicare PIN