Provider Demographics
NPI:1477907905
Name:FERNANDES, CARLO (DO)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:
Last Name:FERNANDES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7916 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1711
Mailing Address - Country:US
Mailing Address - Phone:708-567-0007
Mailing Address - Fax:
Practice Address - Street 1:2313 E HILL RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5059
Practice Address - Country:US
Practice Address - Phone:810-496-0900
Practice Address - Fax:810-695-6497
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine