Provider Demographics
NPI:1629502760
Name:FERNANDEZ, JUAN DIEGO (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:DIEGO
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:625 S FAIR OAKS AVE STE 285
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2613
Practice Address - Country:US
Practice Address - Phone:626-817-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-15
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA185789207WX0109X, 2084N0400X
VA01012658562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology