Provider Demographics
NPI:1700966116
Name:FERNANDEZ, ANGELITO
Entity Type:Individual
Prefix:
First Name:ANGELITO
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764
Mailing Address - Country:US
Mailing Address - Phone:815-844-6123
Mailing Address - Fax:815-884-7851
Practice Address - Street 1:1506 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764
Practice Address - Country:US
Practice Address - Phone:815-844-6123
Practice Address - Fax:815-884-7851
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-053418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053418Medicaid
ILCA2182Medicare ID - Type UnspecifiedRR GROUP #
IL036053418Medicaid
IL080066350Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL080066343Medicare ID - Type UnspecifiedRR INDIVIDUAL #
ILL36621Medicare ID - Type UnspecifiedINDIVIDUAL #
D13030Medicare UPIN