Provider Demographics
NPI:1063866234
Name:FERNANDEZ, LUIS ENRIQUE
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ENRIQUE
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1170 SW BAYSHORE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2408
Mailing Address - Country:US
Mailing Address - Phone:772-309-0020
Mailing Address - Fax:855-538-3104
Practice Address - Street 1:1170 SW BAYSHORE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-2408
Practice Address - Country:US
Practice Address - Phone:772-309-0020
Practice Address - Fax:855-538-3104
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1761208D00000X
PR19469208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR13786-IOtherJUNTA MEDICA DE PR