Provider Demographics
NPI:1942398409
Name:FERNANDES, LACTANCIO (MD)
Entity Type:Individual
Prefix:DR
First Name:LACTANCIO
Middle Name:
Last Name:FERNANDES
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:PO BOX 6418
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6418
Mailing Address - Country:US
Mailing Address - Phone:228-229-7776
Mailing Address - Fax:601-984-5658
Practice Address - Street 1:1107 EARL FRYE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5519
Practice Address - Country:US
Practice Address - Phone:662-256-9590
Practice Address - Fax:662-256-9599
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14203207R00000X, 207RC0200X, 207RG0300X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01578334Medicaid
MSP00821834OtherRAILROAD MEDICARE
MSP00821834OtherRAILROAD MEDICARE