Provider Demographics
NPI:1275500365
Name:JUAREZ, FERNANDO (OTHER)
Entity Type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:
Last Name:JUAREZ
Suffix:
Gender:M
Credentials:OTHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4643 DOCK RD
Mailing Address - Street 2:BLDG 524
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93043-4321
Mailing Address - Country:US
Mailing Address - Phone:805-982-4261
Mailing Address - Fax:805-982-3246
Practice Address - Street 1:4643 DOCK RD
Practice Address - Street 2:BLDG 524
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4321
Practice Address - Country:US
Practice Address - Phone:805-982-4261
Practice Address - Fax:805-982-3246
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
TRIWESTOtherMILITARY