Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 036070990 | IL |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 01040355A | IN |
NPI | 1043218050 |
---|---|
Provider Name | Dr. Henry J Fuentes |
First Address | Palos Heights, IL 60463-1001 |
Second Address | Palos Heights, IL 60463-1001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2005 |
Last Update Date | 12/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E87860 | (02) | IL |