Provider Demographics
NPI:1528037280
Name:FERNANDEZ, JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 LAKE FRST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 MADISON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4744
Practice Address - Country:US
Practice Address - Phone:618-451-1800
Practice Address - Fax:618-451-1526
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6F41207Y00000X
IL207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D16137Medicare UPIN
755660Medicare ID - Type Unspecified