Provider Demographics
NPI:1174828313
Name:DR ANTHONY A FERNANDEZ MD PA
Entity Type:Organization
Organization Name:DR ANTHONY A FERNANDEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:ALVARO
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-876-0502
Mailing Address - Street 1:4600 N HABANA AVE
Mailing Address - Street 2:STE 16
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7112
Mailing Address - Country:US
Mailing Address - Phone:813-876-0502
Mailing Address - Fax:813-872-6503
Practice Address - Street 1:4600 N HABANA AVE
Practice Address - Street 2:STE 16
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7112
Practice Address - Country:US
Practice Address - Phone:813-876-0502
Practice Address - Fax:813-872-6503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0008628261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043154100Medicaid
FL043154100Medicaid