Provider Demographics
NPI:1104817378
Name:FERNANDO, BARRY (MD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:FERNANDO
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 1:2777 E CAMELBACK RD STE 140
Mailing Address - Street 2:140
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4351
Mailing Address - Country:US
Mailing Address - Phone:602-956-3596
Mailing Address - Fax:602-956-4762
Practice Address - Street 1:2777 E CAMELBACK RD STE 140
Practice Address - Street 2:#780
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4351
Practice Address - Country:US
Practice Address - Phone:602-956-3596
Practice Address - Fax:602-956-4762
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ178022086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
BF1512258OtherDEA
BF1512258OtherDEA