Provider Demographics
NPI:1801854625
Name:FERNANDEZ, ENRIQUE JOSE (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:JOSE
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 1:2902 59TH STREET W
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7021
Mailing Address - Country:US
Mailing Address - Phone:941-795-2088
Mailing Address - Fax:941-792-5139
Practice Address - Street 1:2902 59TH STREET W
Practice Address - Street 2:SUITE A
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7021
Practice Address - Country:US
Practice Address - Phone:941-795-2088
Practice Address - Fax:941-792-5139
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00479302086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010008466OtherRAILROAD MEDICARE
FL010008466OtherRAILROAD MEDICARE
FL41247Medicare ID - Type Unspecified