Provider Demographics
NPI:1073675740
Name:FERNANDES, JAXON JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAXON
Middle Name:JAMES
Last Name:FERNANDES
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:PO BOX 708640
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-8640
Mailing Address - Country:US
Mailing Address - Phone:866-869-2395
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:1 CLARA MAASS DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3550
Practice Address - Country:US
Practice Address - Phone:973-450-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08153000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0125237Medicaid
NJP00399307OtherRAIL ROAD MEDICARE
NJP00399307OtherRAIL ROAD MEDICARE
NJ0125237Medicaid