Healthcare Provider Details

I. General information

NPI: 1508811654
Provider Name (Legal Business Name): SHANELI FERNANDO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 REGENCY CT SUITE 207
TOLEDO OH
43623-3092
US

IV. Provider business mailing address

3000 REGENCY CT SUITE 207
TOLEDO OH
43623-3092
US

V. Phone/Fax

Practice location:
  • Phone: 419-471-0493
  • Fax: 419-474-0390
Mailing address:
  • Phone: 419-471-0493
  • Fax: 419-474-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number239860
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberSF078490
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number69611-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number091524
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: