Provider Demographics
NPI:1407856552
Name:DURALDE, FERNANDO A (MD)
Entity Type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:A
Last Name:DURALDE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:1336 HIGHWAY 54 W
Practice Address - Street 2:BLDG 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4535
Practice Address - Country:US
Practice Address - Phone:770-716-9656
Practice Address - Fax:770-716-1609
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2015-01-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA027370208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000439414EMedicaid
GA5371070002Medicare NSC
GA202I340852Medicare PIN
GAF25620Medicare UPIN