Provider Demographics
NPI:1194927863
Name:FERNANDEZ, GREGORY S (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
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 1:615 HOPE ROAD, BUILDING 1
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724
Mailing Address - Country:US
Mailing Address - Phone:848-208-2600
Mailing Address - Fax:848-208-2601
Practice Address - Street 1:615 HOPE ROAD
Practice Address - Street 2:BUILDING 1, 2ND FLOOR
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724
Practice Address - Country:US
Practice Address - Phone:848-208-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1103012084P0800X
NY2442622084P0800X
NJ25MA095383002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02890513Medicaid
NY02890513Medicaid