Provider Demographics
NPI:1760481402
Name:ESCOVAR, FERNANDO S (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:S
Last Name:ESCOVAR
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:2120 RIETH BLVD STE C
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5858
Practice Address - Country:US
Practice Address - Phone:574-875-6911
Practice Address - Fax:574-875-1057
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044055A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000851184OtherBCBS BMG GOSHEN
IN200041830Medicaid
IN000000851184OtherBCBS BMG GOSHEN
IN200041830BMedicaid
IN200041830BMedicaid
IN236040041Medicare PIN
IN000000851184OtherBCBS BMG GOSHEN
IN200041830Medicaid