Provider Demographics
NPI:1770699696
Name:FERNANDES JUNG, FLAVIA (MD)
Entity type:Individual
Prefix:
First Name:FLAVIA
Middle Name:
Last Name:FERNANDES JUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FLAVIA
Other - Middle Name:
Other - Last Name:JUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:238 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2504
Mailing Address - Country:US
Mailing Address - Phone:315-782-9450
Mailing Address - Fax:315-782-1330
Practice Address - Street 1:238 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2504
Practice Address - Country:US
Practice Address - Phone:315-782-9450
Practice Address - Fax:315-782-1330
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2000-016012080P0210X
NY212699208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4131550Medicaid
H02046Medicare UPIN
MDR588Medicare PIN