Provider Demographics
NPI:1396747382
Name:FERNANDEZ, JUAN A (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:A
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 1:2126 W ROY PARKER RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-8566
Mailing Address - Country:US
Mailing Address - Phone:334-774-1200
Mailing Address - Fax:
Practice Address - Street 1:2126 W ROY PARKER RD
Practice Address - Street 2:SUITE 202
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-8566
Practice Address - Country:US
Practice Address - Phone:334-774-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-26392208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS104372Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUM
E72061Medicare UPIN