Provider Demographics
NPI:1417059940
Name:FERNANDEZ, CARLOS HERNANDEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:HERNANDEZ
Last Name:FERNANDEZ
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 1:6545 FRANCE AVE S
Mailing Address - Street 2:SUITE 689
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2131
Mailing Address - Country:US
Mailing Address - Phone:952-927-7095
Mailing Address - Fax:952-927-9594
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE 689
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-927-7095
Practice Address - Fax:952-927-9594
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2036079Medicaid
MN0N069FEOtherBLUE CROSS BLUE SHIELD
MN0421661OtherMEDICA
MN2036079Medicaid
MN0N069FEOtherBLUE CROSS BLUE SHIELD