Provider Demographics
NPI:1902366529
Name:FERNANDEZ, EDWARD ANTHONY
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ANTHONY
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 ROUTE 88
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3071
Mailing Address - Country:US
Mailing Address - Phone:732-458-2000
Mailing Address - Fax:732-458-4523
Practice Address - Street 1:1673 ROUTE 88
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3071
Practice Address - Country:US
Practice Address - Phone:732-458-2000
Practice Address - Fax:732-458-4523
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA12110000207K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program