Provider Demographics
NPI:1487819819
Name:FERNANDEZ, DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
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 1:4886 MANSFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1978
Mailing Address - Country:US
Mailing Address - Phone:520-576-0216
Mailing Address - Fax:
Practice Address - Street 1:14200 W CELEBRATE LIFE WAY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3007
Practice Address - Country:US
Practice Address - Phone:623-207-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41450207ZP0102X
CAA114125207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology