Provider Demographics
NPI:1275597692
Name:FERNANDEZ, ROBERTO DE J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:DE J
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 1:135 W 49TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3711
Mailing Address - Country:US
Mailing Address - Phone:305-822-3657
Mailing Address - Fax:305-826-3177
Practice Address - Street 1:135 W 49 ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:305-822-3657
Practice Address - Fax:305-826-3177
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043363207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043775100Medicaid
FL96946Medicare ID - Type UnspecifiedMCARE
FL043775100Medicaid