Provider Demographics
NPI:1497322630
Name:FERNANDEZ, FULBERT BRAD BELTRAN (PT)
Entity Type:Individual
Prefix:MR
First Name:FULBERT BRAD
Middle Name:BELTRAN
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21143 HAWTHORNE BLVD # 491
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4615
Mailing Address - Country:US
Mailing Address - Phone:760-351-6862
Mailing Address - Fax:
Practice Address - Street 1:22524 MONETA AVE
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3621
Practice Address - Country:US
Practice Address - Phone:760-351-6862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36201208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation