Provider Demographics
NPI:1629813019
Name:FERNANDEZ, JORGE LUIS (MA 101050)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:MA 101050
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10290 SAND CAY DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4286
Mailing Address - Country:US
Mailing Address - Phone:786-781-0756
Mailing Address - Fax:
Practice Address - Street 1:10290 SAND CAY DR
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4286
Practice Address - Country:US
Practice Address - Phone:786-781-0756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101050225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist