Provider Demographics
NPI:1023079670
Name:FERNANDEZ, FERNANDO MIGUEL (DO)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:MIGUEL
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DO
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 16568
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-6568
Mailing Address - Country:US
Mailing Address - Phone:904-472-2300
Mailing Address - Fax:904-472-2330
Practice Address - Street 1:14540 OLD SAINT AUGUSTINE RD STE 2391
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258
Practice Address - Country:US
Practice Address - Phone:904-268-5300
Practice Address - Fax:904-268-5040
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7630207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254722800Medicaid
FL254722800Medicaid
FLG76926Medicare UPIN