Provider Demographics
NPI:1306842133
Name:FERNANDO, KUMUDHINI (MD)
Entity Type:Individual
Prefix:
First Name:KUMUDHINI
Middle Name:
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3774
Mailing Address - Country:US
Mailing Address - Phone:203-932-6481
Mailing Address - Fax:203-932-4051
Practice Address - Street 1:687 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3774
Practice Address - Country:US
Practice Address - Phone:203-932-6481
Practice Address - Fax:203-932-4051
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001167972OtherRAILROAD MEDICARE
CT016797OtherCONNECTICARE
CT0V7684OtherHEALTHNET
CT010016797CT01OtherANTHEM BLUE SHIELD
CTP778776OtherOXFORD
CT2671960OtherAETNA
CT001167972Medicaid
CT001167972OtherRAILROAD MEDICARE
CT010016797CT01OtherANTHEM BLUE SHIELD