Healthcare Provider Details

I. General information

NPI: 1912078510
Provider Name (Legal Business Name): HENRY FERNANDEZ-COS, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 GRAND AVE
ENGLEWOOD NJ
07631-3574
US

IV. Provider business mailing address

419 66TH ST
WEST NEW YORK NJ
07093-2401
US

V. Phone/Fax

Practice location:
  • Phone: 201-816-9636
  • Fax:
Mailing address:
  • Phone: 201-861-9229
  • Fax: 201-861-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA04426200
License Number StateNJ

VIII. Authorized Official

Name: HENRY FERNANDEZ-COS
Title or Position: DELEGATED OFFICIAL
Credential: M.D.
Phone: 201-816-9229