Healthcare Provider Details

I. General information

NPI: 1912940107
Provider Name (Legal Business Name): IVAN J FERNANDEZ-MADRID MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: IVAN MADRID MD

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 2ND AVE
NEW YORK NY
10010-5615
US

IV. Provider business mailing address

205 EAST 16TH STREET SUITE M1B
NEW YORK NY
10003
US

V. Phone/Fax

Practice location:
  • Phone: 212-598-6655
  • Fax:
Mailing address:
  • Phone: 212-254-0946
  • Fax: 212-254-0956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number217407
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: