Provider Demographics
NPI:1417012337
Name:FERNANDES, GREGORY MICHAEL (MD,)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MICHAEL
Last Name:FERNANDES
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8 HUFF RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2932
Mailing Address - Country:US
Mailing Address - Phone:973-696-1140
Mailing Address - Fax:973-470-3568
Practice Address - Street 1:ST MARYS HOSPITAL
Practice Address - Street 2:211 PENNINGTON AVE
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055
Practice Address - Country:US
Practice Address - Phone:973-470-3095
Practice Address - Fax:973-470-3568
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03967600207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC55623Medicare UPIN