1609848274 NPI number — DURESHAHWAR J FERNANDEZ M.D.

Table of content: DURESHAHWAR J FERNANDEZ M.D. (NPI 1609848274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609848274 NPI number — DURESHAHWAR J FERNANDEZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
DURESHAHWAR
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MENDONCA
Provider Other First Name:
DURESHAHWAR
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609848274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 W WINDCREST ST STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78624-4478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-990-1404
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 S MILAM ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78624-4579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-990-1404
Provider Business Practice Location Address Fax Number:
830-992-2841
Provider Enumeration Date:
02/07/2006

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: 207RC0200X , with the licence number:  K8487 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: MD2022-0350 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: MD2022-0350 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: K8487 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1181489-06 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".