Provider Demographics
NPI:1023001963
Name:FERNANDO, NORMAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:NORMAN
Middle Name:M
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 1:6619 N 19TH AVE
Mailing Address - Street 2:STE B
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1631
Mailing Address - Country:US
Mailing Address - Phone:602-254-5777
Mailing Address - Fax:602-253-9771
Practice Address - Street 1:6619 N 19TH AVE
Practice Address - Street 2:STE B
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1631
Practice Address - Country:US
Practice Address - Phone:602-254-5777
Practice Address - Fax:602-253-9771
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2015-12-01
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
AZ15894207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ254293Medicaid
AZ254293Medicaid