Provider Demographics
NPI:1114080215
Name:FERNANDEZ, RICARDO (MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:FERNANDEZ
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 1:12 ROSZEL RD
Mailing Address - Street 2:SUITE A103
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-6234
Mailing Address - Country:US
Mailing Address - Phone:609-419-0123
Mailing Address - Fax:609-419-0126
Practice Address - Street 1:12 ROSZEL RD
Practice Address - Street 2:SUITE A103
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-6234
Practice Address - Country:US
Practice Address - Phone:609-419-0123
Practice Address - Fax:609-419-0126
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA041775002084P0800X, 2084P0802X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE70429Medicare UPIN