Provider Demographics
NPI:1396799656
Name:FERNANDEZ, MARY C (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
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:W180N8085 TOWN HALL RD
Mailing Address - Street 2:HOSPITAL BASED @ COMMUNITY MEMORIAL
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HOSPITAL BASED @ COMMUNITY MEMORIAL
Practice Address - Street 2:W180 N8085 TOWN HALL ROAD
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051
Practice Address - Country:US
Practice Address - Phone:414-805-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18322207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30118400Medicaid
WI30118400Medicaid