Provider Demographics
NPI:1083997456
Name:FERNANDEZ-RODRIGUE, STACY L (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:FERNANDEZ-RODRIGUE
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 1:808 AUTUMN RIVER RUN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4360
Mailing Address - Country:US
Mailing Address - Phone:504-460-6278
Mailing Address - Fax:
Practice Address - Street 1:1316 W ONTARIO ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5220
Practice Address - Country:US
Practice Address - Phone:267-294-8410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT 200248207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine