Provider Demographics
NPI:1669587739
Name:FERNANDEZ, EDMUND J (MD)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:J
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 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1061 E COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086
Practice Address - Country:US
Practice Address - Phone:262-644-2900
Practice Address - Fax:262-644-2980
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00941442OtherRR MEDICARE
WIP00941442OtherRR MEDICARE
H42200Medicare UPIN
WI462364821Medicare PIN