Provider Demographics
NPI:1295195725
Name:DR MANUEL A FERNANDEZ, PA
Entity Type:Organization
Organization Name:DR MANUEL A FERNANDEZ, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-228-5138
Mailing Address - Street 1:12268 TAMIAMI TRL E
Mailing Address - Street 2:SUITE 301
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34113-7946
Mailing Address - Country:US
Mailing Address - Phone:239-228-5138
Mailing Address - Fax:239-228-5245
Practice Address - Street 1:12268 TAMIAMI TRL E
Practice Address - Street 2:SUITE 301
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-7946
Practice Address - Country:US
Practice Address - Phone:239-228-5138
Practice Address - Fax:239-228-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME17907208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD-59587Medicare UPIN