Basic Information
Provider Information
NPI: 1003000472
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FUENTES
FirstName: EDGAR
MiddleName:  
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5800 BELLAIRE BLVD
Address2: STE 112
City: HOUSTON
State: TX
PostalCode: 770815537
CountryCode: US
TelephoneNumber: 7137717867
FaxNumber: 7137717869
Practice Location
Address1: 5800 BELLAIRE BLVD
Address2: STE 112
City: HOUSTON
State: TX
PostalCode: 770815537
CountryCode: US
TelephoneNumber: 7137717867
FaxNumber: 7137717869
Other Information
ProviderEnumerationDate: 08/29/2007
LastUpdateDate: 08/24/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
156FX1800X  Y Eye and Vision Services ProvidersTechnician/TechnologistOptician

No ID Information.


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