Provider Demographics
NPI:1629502935
Name:FERNANDEZ, RICHARD ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
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 1:325 PO BOX
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:NC
Mailing Address - Zip Code:28478-7882
Mailing Address - Country:US
Mailing Address - Phone:910-803-3483
Mailing Address - Fax:
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-615-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02783207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCUUIW1673510201OtherSTUDENT BLUE CROSS BLUE SHIELD