Provider Demographics
NPI:1275567059
Name:PRUNES, FERNANDO SERGIO (MD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:SERGIO
Last Name:PRUNES
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:PO BOX 60159
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93386
Mailing Address - Country:US
Mailing Address - Phone:661-872-7000
Mailing Address - Fax:661-872-0499
Practice Address - Street 1:2201 MT VERNON AVE
Practice Address - Street 2:STE 211
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306
Practice Address - Country:US
Practice Address - Phone:661-872-7000
Practice Address - Fax:661-872-0499
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40476208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A404760Medicaid
C35514Medicare UPIN
CA00A404760Medicare ID - Type Unspecified