Provider Demographics
NPI:1073768891
Name:FERNANDEZ, GENARO (MD)
Entity Type:Individual
Prefix:
First Name:GENARO
Middle Name:
Last Name:FERNANDEZ
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 1:1380 EL CAJON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-5760
Mailing Address - Country:US
Mailing Address - Phone:619-867-0557
Mailing Address - Fax:619-867-0558
Practice Address - Street 1:1380 EL CAJON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-5760
Practice Address - Country:US
Practice Address - Phone:619-867-0557
Practice Address - Fax:619-867-0558
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122302207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03001654/NWKMedicaid
NY01131126/RGHMedicaid
NY03000520/RGHMedicaid
NY03817172Medicaid
NY03007063/NWKMedicaid
UTP00876420OtherMEDICARE RAILROAD
NY03255983Medicaid
UT1073768891Medicaid
NY03000520/RGHMedicaid
NY03007063/NWKMedicaid
NY03255983Medicaid
NY01131126/RGHMedicaid
NYJ400129848/NWKMedicare PIN