Provider Demographics
NPI:1619928116
Name:FERNANDEZ, LUIS ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ANTHONY
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 1:1005 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1601
Mailing Address - Country:US
Mailing Address - Phone:928-776-8428
Mailing Address - Fax:928-776-8057
Practice Address - Street 1:1005 DIVISION ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1601
Practice Address - Country:US
Practice Address - Phone:928-776-8428
Practice Address - Fax:928-776-8057
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05540000207V00000X
AZ37106207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF93755Medicare UPIN