Provider Demographics
NPI:1396742573
Name:FERNANDO, FELICITO E (MD)
Entity type:Individual
Prefix:
First Name:FELICITO
Middle Name:E
Last Name:FERNANDO
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 1:435 25TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3838
Mailing Address - Country:US
Mailing Address - Phone:423-479-9733
Mailing Address - Fax:423-472-1890
Practice Address - Street 1:435 25TH ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3838
Practice Address - Country:US
Practice Address - Phone:423-479-9733
Practice Address - Fax:423-472-1890
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD021401208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNF08255Medicare UPIN