Provider Demographics
NPI:1316117872
Name:FERNANDEZ, EDDIE (MT)
Entity type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 143233
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614
Mailing Address - Country:US
Mailing Address - Phone:787-897-0263
Mailing Address - Fax:787-897-0263
Practice Address - Street 1:CARR 129 KM 21.8
Practice Address - Street 2:BO CALLEJONES
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669
Practice Address - Country:US
Practice Address - Phone:787-897-0263
Practice Address - Fax:787-897-0263
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4047246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0031390Medicare PIN