Provider Demographics
NPI:1689721383
Name:FUENTES, MICHAEL GERARD (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GERARD
Last Name:FUENTES
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 1:5402 WOOLDRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-3837
Mailing Address - Country:US
Mailing Address - Phone:361-888-7716
Mailing Address - Fax:361-888-7718
Practice Address - Street 1:5656 S STAPLES ST
Practice Address - Street 2:STE 252
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4655
Practice Address - Country:US
Practice Address - Phone:361-888-7716
Practice Address - Fax:361-888-7718
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK40622081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030121001Medicaid
TX030121001Medicaid
TXTXB109235Medicare PIN
TX0034CAMedicare ID - Type Unspecified
TXTXB109234Medicare PIN