Healthcare Provider Details

I. General information

NPI: 1194259341
Provider Name (Legal Business Name): MATTHEW FERNANDEZ DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 PHYSICIANS DR
CHARLESTON SC
29414-5719
US

IV. Provider business mailing address

150 CHATHAM MEDICAL PARK
ELKIN NC
28621-2445
US

V. Phone/Fax

Practice location:
  • Phone: 843-571-0602
  • Fax:
Mailing address:
  • Phone: 336-835-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number703
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number771
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number703
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: