Provider Demographics
NPI:1295048213
Name:LI FUENTES, ERICKA VANESA (MD)
Entity type:Individual
Prefix:DR
First Name:ERICKA
Middle Name:VANESA
Last Name:LI 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 1:250 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3490
Mailing Address - Country:US
Mailing Address - Phone:478-301-2362
Mailing Address - Fax:478-301-2272
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-301-2362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097388207R00000X
OH35-131721207R00000X
GA070321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I118164Medicare PIN