Provider Demographics
NPI:1326125030
Name:FERNANDES, BRUCE J
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:J
Last Name:FERNANDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE FERRY
Mailing Address - State:NJ
Mailing Address - Zip Code:07643-1321
Mailing Address - Country:US
Mailing Address - Phone:201-440-5036
Mailing Address - Fax:
Practice Address - Street 1:10 MALL DR. WEST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07310-1601
Practice Address - Country:US
Practice Address - Phone:201-798-4642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00547200152W00000X
NYTUV005833-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7325509Medicaid
NYU67078Medicare UPIN
NJU67078Medicare UPIN
NJ901639Medicare ID - Type Unspecified
NJ7325509Medicaid