Provider Demographics
NPI:1760748644
Name:FERNANDEZ, MARYGOLD LORA (MD)
Entity Type:Individual
Prefix:
First Name:MARYGOLD
Middle Name:LORA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15763 SHOREBIRD LN
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4553
Mailing Address - Country:US
Mailing Address - Phone:407-745-1849
Mailing Address - Fax:407-442-3667
Practice Address - Street 1:2302 NORTH BLVD W STE D
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8920
Practice Address - Country:US
Practice Address - Phone:863-422-1400
Practice Address - Fax:863-422-4616
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCQ009A759Medicare PIN
NCP01648548OtherRAILROAD MEDICARE
NC7485784OtherCIGNA
NCNCQ009A759Medicare PIN