Provider Demographics
NPI:1134121841
Name:FERNANDEZ, IDANIA MELO (MD)
Entity Type:Individual
Prefix:DR
First Name:IDANIA
Middle Name:MELO
Last Name:FERNANDEZ
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 1:3160 W 76TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-3886
Mailing Address - Country:US
Mailing Address - Phone:305-826-8353
Mailing Address - Fax:305-826-8012
Practice Address - Street 1:3160 W 76TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-3886
Practice Address - Country:US
Practice Address - Phone:305-826-8353
Practice Address - Fax:305-826-8012
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82719208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262380300Medicaid
FL262380300Medicaid
FLH54364Medicare UPIN