Provider Demographics
NPI:1558473850
Name:FERNANDO, ISRAEL V (MD)
Entity Type:Individual
Prefix:DR
First Name:ISRAEL
Middle Name:V
Last Name:FERNANDO
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 1:3709 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7208
Mailing Address - Country:US
Mailing Address - Phone:309-797-2713
Mailing Address - Fax:309-797-9558
Practice Address - Street 1:3709 16TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7208
Practice Address - Country:US
Practice Address - Phone:309-797-2713
Practice Address - Fax:309-797-9558
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101791207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2252064Medicaid
IAIB1641Medicare PIN
ILH16762Medicare UPIN
IAI7183Medicare PIN
IA2252064Medicaid