Provider Demographics
NPI:1184015844
Name:FERNANDOPULLE, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:FERNANDOPULLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E DELAWARE PL
Mailing Address - Street 2:UNIT 602
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1031
Mailing Address - Country:US
Mailing Address - Phone:708-663-4051
Mailing Address - Fax:
Practice Address - Street 1:211 E DELAWARE PL
Practice Address - Street 2:UNIT 602
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1031
Practice Address - Country:US
Practice Address - Phone:708-663-4051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program