Provider Demographics
NPI:1407811540
Name:FERNANDEZ-LEON, JOSE M (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:M
Last Name:FERNANDEZ-LEON
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 1:2304 ARRIVISTE WAY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5901
Mailing Address - Country:US
Mailing Address - Phone:850-484-5577
Mailing Address - Fax:850-484-5444
Practice Address - Street 1:4531 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2770
Practice Address - Country:US
Practice Address - Phone:850-484-5577
Practice Address - Fax:850-484-5444
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME37945208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL59116186OtherBLUE CROSS BLUE SHIELD
FL17593OtherBLUE CROSS BLUE SHIELD
E14922Medicare UPIN
FL17593YMedicare ID - Type Unspecified