Provider Demographics
NPI:1578567103
Name:FERNANDEZ, JACINTO JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACINTO
Middle Name:JOSE
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 1:718 TEANECK ROAD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4245
Mailing Address - Country:US
Mailing Address - Phone:201-833-3000
Mailing Address - Fax:201-227-6207
Practice Address - Street 1:222 CEDAR LANE
Practice Address - Street 2:SUITE 207
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4312
Practice Address - Country:US
Practice Address - Phone:201-833-7087
Practice Address - Fax:201-833-7123
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02831100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0297972OtherGHI PPO #
NJ584E41OtherEMPIRE BC/BS #
NJ1060081OtherHORIZON NJ HEALTH #
NJ3080924OtherAETNA HMO #
NJ4208689OtherAETNA PPO #
NJBP368OtherOXFORD PROVIDER #
NJ421565777OtherTAX IDENTIFICATION #
NJ2K1678OtherHEALTHNET #
NJ2K1678OtherHEALTHNET #
NJ3080924OtherAETNA HMO #