Healthcare Provider Details

I. General information

NPI: 1093545089
Provider Name (Legal Business Name): EARVIN JAY FERNANDEZ TANEDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-3238
US

IV. Provider business mailing address

6522 TELEGRAPH AVE
OAKLAND CA
94609-1114
US

V. Phone/Fax

Practice location:
  • Phone: 510-714-0996
  • Fax:
Mailing address:
  • Phone: 510-714-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: