Healthcare Provider Details

I. General information

NPI: 1982924742
Provider Name (Legal Business Name): GREGORY FERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BOTULPH LN
SANTA FE NM
87505-6912
US

IV. Provider business mailing address

401 BOTULPH LN
SANTA FE NM
87505-6912
US

V. Phone/Fax

Practice location:
  • Phone: 631-259-1995
  • Fax:
Mailing address:
  • Phone: 631-259-1995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA167447
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: