Provider Demographics
NPI:1760476923
Name:FERNANDEZ, RODERICK R (MD)
Entity Type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:R
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 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-333-5728
Mailing Address - Fax:814-333-5726
Practice Address - Street 1:1034 GROVE ST
Practice Address - Street 2:751 LIBERTY STREET
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2945
Practice Address - Country:US
Practice Address - Phone:814-333-5728
Practice Address - Fax:814-333-5726
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052861L174400000X, 207L00000X
PA052861L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA050042853Medicaid
PA0014688180001Medicaid
PA117375GC9Medicare UPIN
PAF84244Medicare UPIN