1922072750 NPI number — RONALD F DE LA FUENTE O.D.

Table of content: RONALD F DE LA FUENTE O.D. (NPI 1922072750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922072750 NPI number — RONALD F DE LA FUENTE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA FUENTE
Provider First Name:
RONALD
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.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:
1922072750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3912 GARDENIA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCKINNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75070-4669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-540-9565
Provider Business Mailing Address Fax Number:
214-379-2281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1145 14TH ST
Provider Second Line Business Practice Location Address:
SUITE 2115
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75074-6201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-424-7236
Provider Business Practice Location Address Fax Number:
972-423-0614
Provider Enumeration Date:
02/16/2006

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: 152W00000X , with the licence number:  5936TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 176230401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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