Healthcare Provider Details

I. General information

NPI: 1881644045
Provider Name (Legal Business Name): MARYLOU DAVID FERNANDO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 GARREDD BLVD STE B
AUGUSTA GA
30909-6757
US

IV. Provider business mailing address

2467 GOLDEN CAMP RD
AUGUSTA GA
30906-5515
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-8220
  • Fax: 706-922-5856
Mailing address:
  • Phone: 706-790-4440
  • Fax: 706-790-4393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number028770
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: