Provider Demographics
NPI:1013188408
Name:FERNANDO, GARY PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:PATRICK
Last Name:FERNANDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2112
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:
Practice Address - Street 1:1200 W STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257716208000000X
IL036128459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics