Provider Demographics
NPI:1093121089
Name:FERNANDEZ, CARMEN MARIA (DO)
Entity type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:MARIA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:13214 PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-2025
Practice Address - Country:US
Practice Address - Phone:239-694-7887
Practice Address - Fax:239-694-8941
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FGU25OtherFLORIDA BLUE
FL014864100Medicaid
FLHZ822XMedicare PIN