Provider Demographics
NPI:1487641627
Name:FERNANDEZ, JOSE LUIS (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
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 1:530 CITY PARK DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-1021
Mailing Address - Country:US
Mailing Address - Phone:770-317-6312
Mailing Address - Fax:770-506-4368
Practice Address - Street 1:2201 TALMADGE RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-1608
Practice Address - Country:US
Practice Address - Phone:678-479-1234
Practice Address - Fax:678-479-5678
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA038483207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF80263Medicare UPIN
GAIIBDWTFMedicare ID - Type Unspecified