Provider Demographics
NPI:1255369591
Name:FERNANDEZ, ANTONIO N (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:N
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 1:700 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7314
Mailing Address - Country:US
Mailing Address - Phone:352-867-8311
Mailing Address - Fax:352-867-1053
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:863-294-8400
Practice Address - Fax:863-294-8536
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91190207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271448500Medicaid
FL01574OtherBCBS FL
FL01574OtherBCBS FL
FLU3987WMedicare PIN
FL271448500Medicaid
FLU3987YMedicare PIN
FLI22928Medicare UPIN
FLU3987VMedicare PIN
FLU3987UMedicare PIN
FLP00273732Medicare PIN
FLP00296390Medicare PIN