Provider Demographics
NPI:1407087562
Name:ESCOBAR RENGIFO, FERNANDO ALFONSO (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:ALFONSO
Last Name:ESCOBAR RENGIFO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FERNANDO
Other - Middle Name:ALFONSO
Other - Last Name:ESCOBAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3401 CIVIC CENTER BLVD
Mailing Address - Street 2:CHOP RADIOLOGY
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-590-1000
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:CHOP RADIOLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4422712085R0202X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology