1841299302 NPI number — DR. LUIS FERNANDEZ MD

Table of content: DR. LUIS FERNANDEZ MD (NPI 1841299302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841299302 NPI number — DR. LUIS FERNANDEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
LUIS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841299302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2850 OLYMPUS DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-239-3815
Provider Business Mailing Address Fax Number:
208-239-3814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2850 OLYMPUS DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-239-3815
Provider Business Practice Location Address Fax Number:
208-239-3814
Provider Enumeration Date:
07/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  M8581 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 805465900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: J7871 . This is a "BLUE CROSS (DW)" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: J7855 . This is a "BLUE CROSS (LV)" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: J7863 . This is a "BLUE CROSS (AF)" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 52282 . This is a "BLUE CROSS OF ID (AB)" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: B5763 . This is a "BLUE CROSS (MC)" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: J7889 . This is a "BLUE CROSS (PO)" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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