Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | D2424 | TX |
NPI | 1144232158 |
---|---|
Provider Name | Dr. Antonio Fuentes |
First Address | Corpus Christi, TX 78405-1525 |
Second Address | Corpus Christi, TX 78405-1525 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B22805 | (02) | TX |