Provider Demographics
NPI:1639215718
Name:FERNANDEZ, MADELINE (OD)
Entity Type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-2119
Mailing Address - Country:US
Mailing Address - Phone:908-389-0390
Mailing Address - Fax:908-389-0394
Practice Address - Street 1:253 E BROAD ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-2119
Practice Address - Country:US
Practice Address - Phone:908-389-0390
Practice Address - Fax:908-389-0394
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5245152W00000X
NJ00516152W00000X
NJ5245/00516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU43878Medicare UPIN
NJFE125579Medicare PIN