Healthcare Provider Details

I. General information

NPI: 1891245338
Provider Name (Legal Business Name): JOHANS FERNANDEZ SA-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 S KIRKMAN RD APT 9204
ORLANDO FL
32811-2579
US

IV. Provider business mailing address

PO BOX 811
WINDERMERE FL
34786-0811
US

V. Phone/Fax

Practice location:
  • Phone: 407-755-9495
  • Fax: 407-250-8945
Mailing address:
  • Phone: 407-755-9495
  • Fax: 407-395-2587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number15-763
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: