Provider Demographics
NPI:1467441428
Name:BOCCALANDRO, FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:BOCCALANDRO
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 1:720 GOLDER AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4442
Mailing Address - Country:US
Mailing Address - Phone:432-337-3117
Mailing Address - Fax:432-337-3117
Practice Address - Street 1:720 GOLDER AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4442
Practice Address - Country:US
Practice Address - Phone:432-337-3117
Practice Address - Fax:432-337-3117
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7670174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165808001Medicaid
TX325658YL8DMedicare PIN
TX165808001Medicaid