Healthcare Provider Details

I. General information

NPI: 1669680757
Provider Name (Legal Business Name): TIMOTHY MARTIN FERNANDES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 CAMPUS POINT DRIVE, MAIL CODE 7381
LA JOLLA CA
92037-7381
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-6485
  • Fax: 858-657-7107
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA112514
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: