Provider Demographics
NPI:1710294673
Name:FERNANDEZ, ERNESTO JESUS (DOM)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:JESUS
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 BEE RIDGE RD # 441
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2514
Mailing Address - Country:US
Mailing Address - Phone:941-923-0283
Mailing Address - Fax:
Practice Address - Street 1:2844-2 PROCTOR ROAD SUITE 2
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231
Practice Address - Country:US
Practice Address - Phone:941-923-0283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3062101YM0800X
FL1445171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health