Provider Demographics
NPI:1013117423
Name:LEONARDO S FERNANDEZ, LLC
Entity Type:Organization
Organization Name:LEONARDO S FERNANDEZ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:SEQUERA
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-500-1561
Mailing Address - Street 1:21 CAMBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-2078
Mailing Address - Country:US
Mailing Address - Phone:732-500-1561
Mailing Address - Fax:732-332-0415
Practice Address - Street 1:21 CAMBRIDGE RD
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-2078
Practice Address - Country:US
Practice Address - Phone:732-500-1561
Practice Address - Fax:732-332-0415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03012100261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJFE526212Medicare UPIN