Healthcare Provider Details

I. General information

NPI: 1649230061
Provider Name (Legal Business Name): RODOLFO S FERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 STATE ROAD 60 E STE 500
LAKE WALES FL
33853-4302
US

IV. Provider business mailing address

1255 STATE ROAD 60 E STE 500
LAKE WALES FL
33853-4302
US

V. Phone/Fax

Practice location:
  • Phone: 863-676-8237
  • Fax: 863-676-8207
Mailing address:
  • Phone: 863-676-8237
  • Fax: 863-676-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME74306
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: