Provider Demographics
NPI:1063461671
Name:ISRAEL FERNANDO MD
Entity Type:Organization
Organization Name:ISRAEL FERNANDO MD
Other - Org Name:ADVANCED DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:FERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-797-3713
Mailing Address - Street 1:1588 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7213
Mailing Address - Country:US
Mailing Address - Phone:309-797-2713
Mailing Address - Fax:309-797-9558
Practice Address - Street 1:825 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-4920
Practice Address - Country:US
Practice Address - Phone:319-754-9028
Practice Address - Fax:319-754-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0268292Medicaid
IAI7183Medicare ID - Type Unspecified