1316920069 NPI number — STEPHEN L FERNANDEZ MD

Table of content: STEPHEN L FERNANDEZ MD (NPI 1316920069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316920069 NPI number — STEPHEN L FERNANDEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
STEPHEN
Provider Middle Name:
L
Provider Name Prefix Text:
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:
1316920069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2015 ALEXANDER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36301-3003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-671-1696
Provider Business Mailing Address Fax Number:
334-794-0721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301-3008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-794-9511
Provider Business Practice Location Address Fax Number:
334-794-0721
Provider Enumeration Date:
11/28/2005

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: 2085R0202X , with the licence number:  23206 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X , with the licence number: 23206 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 261080900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000055717 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009997695 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009999881 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009997685 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000891624B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009997705 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 261080900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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