Provider Demographics
NPI:1992803308
Name:FERNANDEZ, JUAN MIGUEL (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:MIGUEL
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 1:2322 NW 28TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-6543
Mailing Address - Country:US
Mailing Address - Phone:305-633-3667
Mailing Address - Fax:305-633-3664
Practice Address - Street 1:2322 NW 28TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-6543
Practice Address - Country:US
Practice Address - Phone:305-633-3667
Practice Address - Fax:305-633-3664
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100705207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280609600Medicaid
ME100705OtherFLORIDA LICENCE
ME100705OtherFLORIDA LICENCE