Provider Demographics
NPI:1649282641
Name:FUENTES, RANDY ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:ANTHONY
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 1:1101 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78405-1525
Mailing Address - Country:US
Mailing Address - Phone:361-884-0811
Mailing Address - Fax:361-884-0812
Practice Address - Street 1:1101 S 19TH ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1525
Practice Address - Country:US
Practice Address - Phone:361-884-0811
Practice Address - Fax:361-884-0812
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114342205Medicaid
TX114342205Medicaid
TX00341QMedicare ID - Type Unspecified