Provider Demographics
NPI:1881644045
Name:FERNANDO, MARYLOU DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYLOU
Middle Name:DAVID
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2467 GOLDEN CAMP RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-5515
Mailing Address - Country:US
Mailing Address - Phone:706-790-4440
Mailing Address - Fax:706-790-4393
Practice Address - Street 1:1113 GARREDD BLVD STE B
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6757
Practice Address - Country:US
Practice Address - Phone:706-364-8220
Practice Address - Fax:706-922-5856
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2021-02-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA028770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00344132HMedicaid
GA00344132HMedicaid