Provider Demographics
NPI:1851399539
Name:FERNANDEZ, JUAN CONSTANTINO (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CONSTANTINO
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 1:19 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:RED HOOK
Mailing Address - State:NY
Mailing Address - Zip Code:12571-1424
Mailing Address - Country:US
Mailing Address - Phone:845-758-8896
Mailing Address - Fax:
Practice Address - Street 1:19 E MARKET ST
Practice Address - Street 2:
Practice Address - City:RED HOOK
Practice Address - State:NY
Practice Address - Zip Code:12571-1424
Practice Address - Country:US
Practice Address - Phone:845-758-8896
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY117097OtherMVP HEALTH PLAN
NY00214613Medicaid
NY117097OtherMVP HEALTH PLAN
NYC10670Medicare UPIN