Provider Demographics
NPI:1952383119
Name:FERNANDO, COLEENE (MD)
Entity Type:Individual
Prefix:
First Name:COLEENE
Middle Name:
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 E CAMELBACK RD
Mailing Address - Street 2:140
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4347
Mailing Address - Country:US
Mailing Address - Phone:602-956-3596
Mailing Address - Fax:602-956-4762
Practice Address - Street 1:2777 E CAMELBACK RD
Practice Address - Street 2:140
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4347
Practice Address - Country:US
Practice Address - Phone:602-956-3596
Practice Address - Fax:602-956-4762
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2921207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12921Medicare ID - Type Unspecified