Provider Demographics
NPI:1457336513
Name:FERNANDEZ, ADOLFO ZACARIAS JR (MD)
Entity Type:Individual
Prefix:
First Name:ADOLFO
Middle Name:ZACARIAS
Last Name:FERNANDEZ
Suffix:JR
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-6637
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-6637
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300597208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10012252Medicaid
WV2005465000Medicaid
134GCOtherBCBS
NC89134GCMedicaid
802973OtherPARTNERS
7989604OtherAETNA
C6800OtherMEDCOST
C6800OtherMEDCOST
NC89134GCMedicaid