Healthcare Provider Details

I. General information

NPI: 1124253752
Provider Name (Legal Business Name): MARLYN FERNANDEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 HIGHLAND AVE STE 301
GLEN RIDGE NJ
07028-1522
US

IV. Provider business mailing address

PO BOX 419430
BOSTON MA
02241-9430
US

V. Phone/Fax

Practice location:
  • Phone: 973-744-3733
  • Fax: 973-707-5821
Mailing address:
  • Phone: 201-967-8221
  • Fax: 201-483-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number25MA09223600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: