Provider Demographics
NPI:1841559713
Name:FERNANDEZ, JOSE R
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5637 NORTH COURTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-2907
Mailing Address - Country:US
Mailing Address - Phone:847-292-1489
Mailing Address - Fax:847-292-1489
Practice Address - Street 1:5637 NORTH COURTLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-2907
Practice Address - Country:US
Practice Address - Phone:847-292-1489
Practice Address - Fax:847-292-1489
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine