Provider Demographics
NPI:1952536088
Name:FUENTES LOPEZ, WILFREDO (MD)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:FUENTES LOPEZ
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 1:119 CALLE ORQUIDEA
Mailing Address - Street 2:LOS CAMINOS
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754
Mailing Address - Country:US
Mailing Address - Phone:787-529-6129
Mailing Address - Fax:
Practice Address - Street 1:371 CALLE DE DIEGO
Practice Address - Street 2:
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-754-4244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17577208D00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRCT327AMedicare PIN