Provider Demographics
NPI:1144230491
Name:FERNANDEZ, JOSE P JR (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:P
Last Name:FERNANDEZ
Suffix:JR
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5620
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1 LINCOLN PKWY STE 302
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3261
Practice Address - Country:US
Practice Address - Phone:601-268-5620
Practice Address - Fax:601-268-5851
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS151402084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1484091Medicaid
MS1559337OtherAMERICAN ADMIN GROUP
MS00123815Medicaid
130023107OtherRAILROAD MEDICARE
G62828Medicare UPIN
MS00123815Medicaid