Provider Demographics
NPI:1801824545
Name:FERNZ, MIRIAM MINU (MD)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:MINU
Last Name:FERNZ
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 1:626 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-3708
Mailing Address - Country:US
Mailing Address - Phone:910-642-3356
Mailing Address - Fax:910-642-5433
Practice Address - Street 1:626 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472
Practice Address - Country:US
Practice Address - Phone:910-642-3356
Practice Address - Fax:910-642-5433
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891051NMedicaid
NC1051NOtherBLUE CROSS BLUE SHIELD
NC1051NOtherBLUE CROSS BLUE SHIELD
NC891051NMedicaid