Provider Demographics
NPI:1124069752
Name:FERNANDEZ, AGUSTIN (MD)
Entity type:Individual
Prefix:
First Name:AGUSTIN
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 1:3401 SPRINGHILL DR
Mailing Address - Street 2:STE 400
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-2924
Mailing Address - Country:US
Mailing Address - Phone:501-945-3343
Mailing Address - Fax:501-945-0770
Practice Address - Street 1:3401 SPRINGHILL DR
Practice Address - Street 2:STE 400
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2924
Practice Address - Country:US
Practice Address - Phone:501-945-3343
Practice Address - Fax:501-945-0770
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN5678174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4205587OtherAETNA HEALTHCARE
AR100005435OtherUHC RAILROAD MEDICARE
AR51650OtherAR BLUE CROSS BLUE SHIELD
AR51650OtherHEALTH ADVANTAGE
AR105232001Medicaid
AR51650OtherBLUE ADVANTAGE
AR51650OtherFIRST SOURCE
AR11415000000OtherQUALCHOICE
AR7106445040014OtherCIGNA HEALTHCARE
AR710644504005OtherUNITED HEALTHCARE
AR4205587OtherAETNA HEALTHCARE
AR51650OtherAR BLUE CROSS BLUE SHIELD