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Organization
GWEN FUENTES MD PEDIATRIC CLINIC
Active
Organization
GWEN FUENTES MD PEDIATRIC CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GWEN CANARIAS FUENTES M.D. (OWNER)
(580) 223-5693
Entity
Organization
Contact information
Practice address
919 15TH AVE NW, ARDMORE, OK 73401-1809
(580) 223-5693
(580) 223-8909
Mailing address
919 15TH AVE NW, ARDMORE, OK 73401-1809
(580) 223-5693
(580) 223-8909
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
13171
OK
261QM2500X
Medical Specialty Clinic/Center
Primary
13171
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100209330A
—
OK
05
—
100209330C
—
OK
Enumeration date
04/18/2007
Last updated
01/30/2011
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