1023079670 NPI number — FERNANDO MIGUEL FERNANDEZ D.O.

Table of content: FERNANDO MIGUEL FERNANDEZ D.O. (NPI 1023079670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023079670 NPI number — FERNANDO MIGUEL FERNANDEZ D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
FERNANDO
Provider Middle Name:
MIGUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1023079670
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16568
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32245-6568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-472-2300
Provider Business Mailing Address Fax Number:
904-472-2330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14540 OLD SAINT AUGUSTINE RD STE 2391
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-268-5300
Provider Business Practice Location Address Fax Number:
904-268-5040
Provider Enumeration Date:
03/31/2006

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: 207VG0400X , with the licence number:  OS7630 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 254722800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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