Provider Demographics
NPI:1508811654
Name:FERNANDO, SHANELI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANELI
Middle Name:
Last Name:FERNANDO
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 1:3000 REGENCY CT
Mailing Address - Street 2:SUITE 207
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-3092
Mailing Address - Country:US
Mailing Address - Phone:419-471-0493
Mailing Address - Fax:419-474-0390
Practice Address - Street 1:3000 REGENCY CT
Practice Address - Street 2:SUITE 207
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3092
Practice Address - Country:US
Practice Address - Phone:419-471-0493
Practice Address - Fax:419-474-0390
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2398602085R0001X
MISF0784902085R0001X
WI69611-202085R0001X
OH0915242085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508811654Medicaid
OH2837005Medicaid
OHP00630915OtherRR MEDICARE
MIP00630915OtherRR MEDICARE
MI0N24000018OtherMI MEDICARE
MI1508811654OtherMI MEDICAID - OH LOCATIONS
OHFE4233361Medicare PIN