Healthcare Provider Details

I. General information

NPI: 1053678052
Provider Name (Legal Business Name): ALEXANDER FERNANDO SAN DIEGO JR. D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 N COURTENAY PKWY
MERRITT ISLAND FL
32953-4191
US

IV. Provider business mailing address

2404 N COURTENAY PKWY
MERRITT ISLAND FL
32953-4191
US

V. Phone/Fax

Practice location:
  • Phone: 321-452-1327
  • Fax: 321-454-9208
Mailing address:
  • Phone: 321-452-1327
  • Fax: 321-454-9208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3686
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: