# GWEN FUENTES MD PEDIATRIC CLINIC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1083830608
- **Authorized official:** DR. GWEN CANARIAS FUENTES M.D. (OWNER)
- **Authorized official phone:** (580) 223-5693

## Contact information

- **Practice address:** 919 15TH AVE NW, ARDMORE, OK 73401-1809
- **Practice address phone:** (580) 223-5693
- **Practice address fax:** (580) 223-8909
- **Mailing address:** 919 15TH AVE NW, ARDMORE, OK 73401-1809
- **Mailing address phone:** (580) 223-5693
- **Mailing address fax:** (580) 223-8909

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208000000X | Pediatrics Physician | 13171 | OK | — |
| 261QM2500X | Medical Specialty Clinic/Center | 13171 | OK | Yes |

## Other

- **Enumeration date:** 04/18/2007
- **Last updated:** 01/30/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100209330A | — | OK |
| 05 | — | 100209330C | — | OK |