Provider Demographics
NPI:1073589883
Name:FERNANDES, JOHN
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:FERNANDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 KOEWING PL
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:212-304-7250
Mailing Address - Fax:212-544-1974
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:COLUMBIA UNIVERSITY DEPARTMT .PEDIATRIC
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-304-7250
Practice Address - Fax:212-544-1974
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1752522080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01851101Medicaid
NJ002673OtherMEDICARE PTAN
NYF98635Medicare UPIN
NY01851101Medicaid
NY01G7038381Medicare PIN