Provider Demographics
NPI:1679520423
Name:LA FUENTE, HENRY (BCO, BADO)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:
Last Name:LA FUENTE
Suffix:
Gender:M
Credentials:BCO, BADO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 N ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-4918
Mailing Address - Country:US
Mailing Address - Phone:405-236-2882
Mailing Address - Fax:405-236-3335
Practice Address - Street 1:1116 N ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-4918
Practice Address - Country:US
Practice Address - Phone:405-236-2882
Practice Address - Fax:405-236-3335
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224P00000X, 229N00000X
OK331034873156FX1700X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK331034873OtherTAX ID
OK1811194368OtherGROUP NPI
OK100807050AMedicaid
OK5200600001Medicare ID - Type Unspecified