Healthcare Provider Details

I. General information

NPI: 1023079670
Provider Name (Legal Business Name): FERNANDO MIGUEL FERNANDEZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 OLD SAINT AUGUSTINE RD STE 2391
JACKSONVILLE FL
32258
US

IV. Provider business mailing address

PO BOX 16568
JACKSONVILLE FL
32245-6568
US

V. Phone/Fax

Practice location:
  • Phone: 904-268-5300
  • Fax: 904-268-5040
Mailing address:
  • Phone: 904-472-2300
  • Fax: 904-472-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberOS7630
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: