Provider Demographics
NPI:1477624773
Name:FERNANDEZ, CLARISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARISSA
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 CALLE SOL
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-3946
Mailing Address - Country:US
Mailing Address - Phone:787-892-7546
Mailing Address - Fax:787-892-7411
Practice Address - Street 1:1 CALLE FERROCARRIL
Practice Address - Street 2:SUITE 3
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-4038
Practice Address - Country:US
Practice Address - Phone:787-892-7546
Practice Address - Fax:787-892-7411
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15744208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0023010Medicare ID - Type Unspecified
PRI 27849Medicare UPIN