Provider Demographics
NPI:1780880203
Name:MARTA R FERNANDEZ MD P A
Entity type:Organization
Organization Name:MARTA R FERNANDEZ MD P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:305-608-0524
Mailing Address - Street 1:2500 DEL PRADO BLVD S
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5750
Mailing Address - Country:US
Mailing Address - Phone:239-772-1194
Mailing Address - Fax:239-772-1196
Practice Address - Street 1:2500 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-5750
Practice Address - Country:US
Practice Address - Phone:239-772-1194
Practice Address - Fax:239-772-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90692208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME90692OtherMEDICAL LICENSE
FL268370900OtherMEDICAID PROVIDER
FLAG049Medicare PIN
FLME90692OtherMEDICAL LICENSE