Provider Demographics
NPI:1528297264
Name:FUENTES TIRADO, ELIAM MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:ELIAM
Middle Name:MANUEL
Last Name:FUENTES TIRADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13136 WOODFORD ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832
Mailing Address - Country:US
Mailing Address - Phone:787-955-0232
Mailing Address - Fax:
Practice Address - Street 1:831 S STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-3502
Practice Address - Country:US
Practice Address - Phone:407-256-3456
Practice Address - Fax:407-730-2176
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114560208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008323300Medicaid
FLHF487ZMedicare PIN