Provider Demographics
NPI:1184676611
Name:FERNANDEZ, VIVIAN L (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:L
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 1:3000 WATERCOVE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3982
Mailing Address - Country:US
Mailing Address - Phone:804-744-0200
Mailing Address - Fax:804-744-8417
Practice Address - Street 1:3000 WATERCOVE RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3982
Practice Address - Country:US
Practice Address - Phone:804-744-0200
Practice Address - Fax:804-744-8417
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA60534OtherOPTIMA
VA0100286OtherUNITED HEALTHCARE
VA540883363OtherCHAMPUS-TRICARE
VA540883363OtherPHCS
VA5633842Medicaid
VA116047OtherANTHEM
VA540883363OtherFIRST HEALTH/CCN
VA856731OtherMAMSI
VA540189OtherAETNA
VA540883363OtherGREAT WEST HEALTHCARE
VA540883363OtherPREFERRED CARE
VA540883363OtherVIRGINIA HEALTH NETWORK
VA82535OtherSOUTHERN HEALTH
VA10488OtherCIGNA
VA540883363OtherPHCS
VA016340V28Medicare PIN
VA82535OtherSOUTHERN HEALTH
VA540883363OtherVIRGINIA HEALTH NETWORK
VA080006615Medicare PIN