Healthcare Provider Details

I. General information

NPI: 1184988503
Provider Name (Legal Business Name): PAUL WILLIAM FERNANDES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WASHINGTON RD
WEST POINT NY
10996-1109
US

IV. Provider business mailing address

900 WASHINGTON RD
WEST POINT NY
10996-1109
US

V. Phone/Fax

Practice location:
  • Phone: 315-774-8648
  • Fax: 315-774-8731
Mailing address:
  • Phone: 315-774-8648
  • Fax: 315-774-8731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberC2-0023900
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC2-0023900
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: