1174770614 NPI number — DR. HENRIQUE JOSE FERNANDEZ MD

Table of content: DR. HENRIQUE JOSE FERNANDEZ MD (NPI 1174770614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174770614 NPI number — DR. HENRIQUE JOSE FERNANDEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
HENRIQUE
Provider Middle Name:
JOSE
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:
FERNANDEZ ANGULO
Provider Other First Name:
HENRIQUE
Provider Other Middle Name:
JOSE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1174770614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5820 GLADSTONE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80906-8256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-576-0263
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 N GRAND AVE
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81003-2749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-595-7680
Provider Business Practice Location Address Fax Number:
719-595-7687
Provider Enumeration Date:
08/27/2008

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: 207RG0100X , with the licence number:  MD-50732 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 98813 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: TRN11230 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 48454 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 75771055 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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