1629271580 NPI number — DR. LUIS FERNANDEZ DE LA FUENTE M.D.

Table of content: DR. LUIS FERNANDEZ DE LA FUENTE M.D. (NPI 1629271580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629271580 NPI number — DR. LUIS FERNANDEZ DE LA FUENTE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA FUENTE
Provider First Name:
LUIS
Provider Middle Name:
FERNANDEZ
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629271580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 QUINCY AVE
Provider Second Line Business Mailing Address:
5TH FL
Provider Business Mailing Address City Name:
SCRANTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18510-1798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-770-7546
Provider Business Mailing Address Fax Number:
570-770-7545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 QUINCY AVE
Provider Second Line Business Practice Location Address:
5TH FL
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18510-1798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-340-2552
Provider Business Practice Location Address Fax Number:
570-340-2446
Provider Enumeration Date:
06/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080N0001X , with the licence number:  MD071376L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001845744 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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