Provider Demographics
NPI:1952892895
Name:FERNANDES, CORY JAMES (DO)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:JAMES
Last Name:FERNANDES
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-4103
Mailing Address - Country:US
Mailing Address - Phone:818-388-9705
Mailing Address - Fax:
Practice Address - Street 1:4481 VIKING DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-7414
Practice Address - Country:US
Practice Address - Phone:318-626-2593
Practice Address - Fax:318-399-7716
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-26
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT4919207Q00000X
LA341893207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty