Healthcare Provider Details

I. General information

NPI: 1275656449
Provider Name (Legal Business Name): JUAN CARLOS FERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11031 US HIGHWAY 19 STE 102
PORT RICHEY FL
34668-2213
US

IV. Provider business mailing address

11031 US HIGHWAY 19 STE 102
PORT RICHEY FL
34668-2213
US

V. Phone/Fax

Practice location:
  • Phone: 813-488-4801
  • Fax:
Mailing address:
  • Phone: 813-488-4801
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301119074
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN258
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number16640
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: