Provider Demographics
NPI:1528116365
Name:FUENTES, MARYLUZ (MD)
Entity type:Individual
Prefix:DR
First Name:MARYLUZ
Middle Name:
Last Name:FUENTES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BROWN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7005
Mailing Address - Country:US
Mailing Address - Phone:334-273-4508
Mailing Address - Fax:334-273-4290
Practice Address - Street 1:470 TAYLOR RD
Practice Address - Street 2:SUITE 310
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3563
Practice Address - Country:US
Practice Address - Phone:334-244-4322
Practice Address - Fax:334-244-4321
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME131656207Q00000X
NJ25MA10365200207Q00000X
PAMD466152207Q00000X
VT042.0014217207Q00000X
NY296818207Q00000X
MA276775207Q00000X
AL00024127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51542765OtherBCBS
AL1528116365OtherVIVA
ALH43033OtherHEALTHSPRING
AL009963665Medicaid
ALH43033OtherHEALTHSPRING
AL009963665Medicaid