Provider Demographics
NPI:1841299302
Name:FERNANDEZ, LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
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 1:2850 OLYMPUS DR.
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-239-3815
Mailing Address - Fax:208-239-3814
Practice Address - Street 1:2850 OLYMPUS DR.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-239-3815
Practice Address - Fax:208-239-3814
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805465900Medicaid
IDJ7871OtherBLUE CROSS (DW)
IDJ7855OtherBLUE CROSS (LV)
IDJ7863OtherBLUE CROSS (AF)
ID52282OtherBLUE CROSS OF ID (AB)
IDB5763OtherBLUE CROSS (MC)
IDJ7889OtherBLUE CROSS (PO)
IDH84689Medicare UPIN
IDJ7863OtherBLUE CROSS (AF)
1109443Medicare PIN
1109444Medicare PIN
IDJ7889OtherBLUE CROSS (PO)
1109445Medicare PIN