Provider Demographics
NPI:1306842950
Name:ZAMUDIO, FERNANDO ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:ANTONIO
Last Name:ZAMUDIO
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 22211
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92192-2211
Mailing Address - Country:US
Mailing Address - Phone:619-583-0511
Mailing Address - Fax:619-582-2012
Practice Address - Street 1:6655 ALVARADO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5208
Practice Address - Country:US
Practice Address - Phone:619-583-0511
Practice Address - Fax:619-582-2012
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2011-03-21
Deactivation Date:2006-03-29
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CAC26245207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C262450Medicaid
CA00C262450OtherBLUE SHIELD
CA756061700OtherRR MEDICARE
CA00C262450Medicaid
CA756061700OtherRR MEDICARE