Provider Demographics
NPI:1053360966
Name:FUENTES, EDWIN L (DO)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:L
Last Name:FUENTES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 DEER RUN RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2863
Mailing Address - Country:US
Mailing Address - Phone:434-791-0306
Mailing Address - Fax:434-791-0310
Practice Address - Street 1:2509 RICHARDSON DR STE A
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5926
Practice Address - Country:US
Practice Address - Phone:336-552-4274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102050134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9701749OtherSTATE LICENSE NORTH CAROLINA
VA005641870Medicaid
NCFF0819017OtherDEA