Provider Demographics
NPI:1881860013
Name:FERNANDEZ, MARK MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:MICHAEL
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 1:1133 CAMBRIDGE CRES
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-1221
Mailing Address - Country:US
Mailing Address - Phone:520-245-4733
Mailing Address - Fax:
Practice Address - Street 1:885 KEMPSVILLE ROAD, SUITE 101
Practice Address - Street 2:VIRGINIA OPHTHALMOLOGY ASSOCIATES, PC
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502
Practice Address - Country:US
Practice Address - Phone:757-461-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC141993207W00000X
VA0101251330207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101251330OtherVIRGINIA MEDICAL LICENSE
141993OtherNORTH CAROLINA MEDICAL BOARD CERTIFICATE NUMBER
VA1881860013Medicaid