Provider Demographics
NPI:1356668875
Name:FERNANDEZ, RAMON ANTONIO L (PT)
Entity Type:Individual
Prefix:
First Name:RAMON ANTONIO
Middle Name:L
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3371 CLEVELAND ROAD EXT
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9780
Mailing Address - Country:US
Mailing Address - Phone:574-271-2558
Mailing Address - Fax:574-273-1137
Practice Address - Street 1:51738 SAGECREST DR
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-6887
Practice Address - Country:US
Practice Address - Phone:574-339-5959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2010-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006455A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist