Provider Demographics
NPI:1205368701
Name:FERNANDEZ, EDGAR SERGE (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:SERGE
Last Name:FERNANDEZ
Suffix:
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 1:10414 N MIAMI AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33150-1256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7800 SW 87TH AVE STE B260
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3570
Practice Address - Country:US
Practice Address - Phone:305-595-4590
Practice Address - Fax:305-279-2278
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143670207R00000X, 207RI0200X
MN3008207RI0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109063800Medicaid
FLME143670OtherSTATE LICENSE