Provider Demographics
NPI:1639103138
Name:FERNANDEZ, GEOVER (MD)
Entity Type:Individual
Prefix:
First Name:GEOVER
Middle Name:
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 1:520 N PROSPECT AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3041
Mailing Address - Country:US
Mailing Address - Phone:310-798-1515
Mailing Address - Fax:310-798-3131
Practice Address - Street 1:520 N PROSPECT AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3041
Practice Address - Country:US
Practice Address - Phone:310-798-1515
Practice Address - Fax:310-798-3131
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103070207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00980455OtherMEDICARE RAILROAD PTAN
CAP00980455OtherMEDICARE RAILROAD PTAN