Provider Demographics
NPI:1437136074
Name:FERN, SAMUEL J (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:FERN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 44004
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4004
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-249-0347
Practice Address - Street 1:900 BEACH BLVD
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4368
Practice Address - Country:US
Practice Address - Phone:904-249-0335
Practice Address - Fax:904-249-0347
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3704556-00Medicaid
FL3704556-00Medicaid
E89696Medicare UPIN