Provider Demographics
NPI:1043631591
Name:FERNANDO, JUDITH SHEOLIE (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:SHEOLIE
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 WASHINGTON STREET NEWTON
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-0001
Mailing Address - Country:US
Mailing Address - Phone:617-259-1895
Mailing Address - Fax:
Practice Address - Street 1:313 WASHINGTON STREET NEWTON
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458
Practice Address - Country:US
Practice Address - Phone:617-259-1895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-01
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2771242084P0800X, 2084P0804X
DCMTL0014442084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty