Provider Demographics
NPI:1316676141
Name:SOARES FERNANDES, FLAVIA REGINA (MD STUDENT)
Entity type:Individual
Prefix:
First Name:FLAVIA
Middle Name:REGINA
Last Name:SOARES FERNANDES
Suffix:
Gender:F
Credentials:MD STUDENT
Other - Prefix:
Other - First Name:FLAVIA
Other - Middle Name:REGINA SOARES
Other - Last Name:FERNANDES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-7201
Mailing Address - Country:US
Mailing Address - Phone:214-648-2148
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-648-2148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program